Just hours after landing, on the way to meet my host in the city of Pouso Alegre, I found myself stranded on the side of the road in backcountry Brazil. This was my first time travelling abroad alone, I was without a functioning mobile phone and was acutely aware that I could hardly have been more conspicuous as a ‘gringo’ (foreigner), what with my blue eyes, blond hair, and huge red suitcase.
The bus had broken down and I was standing with the other passengers in a field, wondering how on earth I was going to get to my destination. All this in the context of a media coverage in the run-up to the Olympics which had portrayed Brazil as plagued by administrational incompetence, poverty and violent crime. Needless to say, I was feeling quite on edge.
Fortunately, realising I was a foreigner, the other passengers allowed me to borrow their phones and a group of us chatted away for an hour or two, eating traditional ‘pão de quijo’ that one of them shared out, while waiting for the next bus. The locals wanted me to feel welcome and to tell me about the better side of their country. I had been in Brazil for a matter of hours, but had already made my first friends. Such goodwill set the tone for the next month, in which I was touched by the warmth and generosity of the Brazilian people.
Neurosurgery in Minas Gerais
Yes, I’ve been to Brazil once before, to do a placement in neurosurgery through an international exchange programme for medical students. I never published anything about my experience at the time, so I thought I’d share something in retrospect.
My destination was Minas Gerais, a state famous for its cheese and coffee and stereotyped by Brazilians as being very ‘caipira’ or countrified – think cowboys with plaid shirts and straw hats, horses and carts and dusty country lanes.
My hospital, called Hospital das Clínicas Samuel Libânio, was located in the small city of Pouso Alegre (population: 140,000; or about the same size as Oxford), located inland and close (at least in Brazilian terms) to both Sao Paulo and Rio de Janeiro (a 3 or a 5 hour drive respectively).
Relatively rural, yes, but the proximity to Sao Paulo and Rio meant the experience was quite different to what I’ll probably find this time in Recife, which is a significantly more deprived area of the country – remember, Brazil is a country the size of a continent and there’s enormous variation in living conditions across the country!
Despite being in the south east, which is the most economically developed of Brazil’s four regions, I still witnessed stabbings, road traffic accidents, tropical neuro-infectious diseases and a whole approach to medicine which was somewhat different to that of the NHS.
The hospital there receives both private and public patients, although the private and public areas of the hospital are separated from one another – almost as if they were two separate hospitals – and medical students generally only work in the public areas of the hospital.
I was assigned to work with the neurosurgical team and spent the majority of my time shadowing the trainee neurosurgeons, who were between one and four years out of medical school. Though these trainees had not long finished medical school and were relatively young, I was impressed by their competence.
Neurosurgeons in Brazil do a lot more than neurosurgeons in the UK!
Although formally this was a neurosurgical placement, with the neurosurgeons at this hospital I saw a lot of patients that in the UK would be seen by other specialities. There was very rarely a neurologist on call, so the neurosurgeons saw all the patients with anything remotely neurological, including headaches, strokes, TIAs, seizures and even ‘medical’ patients with acute confusion.
The neurosurgeons also see a lot of paediatric patients with seizures and headaches etc. who would probably normally get seen by the paediatricians in the UK. In addition, there were no neuro-radiologists in the hospital, so the on call neurosurgical trainee has the responsibility of reporting all the brain and spinal imaging.
What can I say I learnt?
I did a lot of reflection on how the healthcare system works in Brazil, and made several observations during my time there, but for now, I thought I’d pick on one particular theme:
Guidelines, protocols, algorithms and evidence-based medicine matter less in Brazil
Here in the UK we are used to seeing patient notes and bedside folders stuffed full of sheets of things which have to be done, checked-off or filled in and signed: thromboprophylaxis risk assessments, DNACPR forms, MUST scores, Warterlow scores, NEWS scores etc. Even the medical clerking (the history taken by doctors when patients first come into hospitals) is completed using a template that helps to remind the doctor of all the key areas of the history and examination. We seem to have a form for everything.
By contrast, the patient notes in Brazil consisted of just a few tidy sheets of essential clinical information which were updated every day. It was a relief not to see a single tick-box exercise during my time in hospital.
Targets in Brazil are also conspicuous by their absence. There is no target for emergency department waiting times, surgery waiting lists or ‘door to needle time’ for stroke treatment. Clinicians operate free from the fear of performing poorly in the next round of audit. Staff simply focus on providing the best quality of care they can and getting patients through the busy emergency department as efficiently and safely as possible.
In general, far less emphasis is placed on guidelines, protocols and ‘evidence-based medicine’. Instead, doctors have greater freedom to exercise professional judgement and tailor treatment to the patient in front of them. Doctors also seem to rely more on personal clinical experience (or that passed down through teaching) – I didn’t once see a doctor referring to the latest guidelines for management of a particular condition.
Does this matter at all?
Based on my anecdotal experience alone, it’s difficult to say whether this reduced emphasis on guidelines and protocols actually affects the quality of care that patients receive. It would be interesting to know whether patient outcomes differ substantially from those in the UK, but this would have required some sort of organised data collection.
My personal feeling is that the freedom from inconsequential targets and burdensome paperwork allows doctors in Brazil to focus on the individual patient and promotes professional independence. However, I do wonder whether the introduction of certain additional protocols, such as the WHO Surgical Safety Checklist, might result in improved patient outcomes.
Some final thoughts
Brazilians might just be some of the friendliest people I have ever met; I was received with open arms everywhere I went. Staff and other students were approachable and keen to teach and exchange perspectives on medicine with a foreigner.
Brazilians like to joke a lot, even in hospital.
The atmosphere in hospital was a lot more informal than it is in the UK. Staff were constantly having fun and joking around but I thought this workplace banter was fantastic; this kept morale high and created a close-knit team – and strong teams ultimately function better for patients.
Coming back to the UK
How can I say that the trip helped me develop personally and professionally? Well, for a start, I came back to the UK with a new appreciation for the fact that that good, patient-focused medicine can be practiced without recourse to guidelines and protocols.
Perhaps more importantly though, I returned with a renewed enthusiasm for my profession and a desire to emulate the positive aspects of the ‘Brazilian way’ in my working life.
Let’s hope that my trip to Brazil this time round has the same effect!