Why do foreign internist doctors choose Portugal for their internship?

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Elisa is an Italian doctor and arrived in Portugal speaking her mother tongue almost correctly to do an internship at one of the Centers of Excellence of the European Rheumatology Network, at Santa Maria Hospital. Thaís, Letícia, Teófilo, and Everton came from Brazil to deepen their knowledge, clinical practice, and the techniques used in Gastroenterology at the same hospital. The international referencing of the services and the renown of the professionals led them to this choice.

Friday. Early afternoon. Elisa Fiorentini, 29 years old, Italian doctor, says goodbye to the Rheumatology Department at Santa Maria Hospital, in Lisbon. Early the next day, she returns to Italy and to her unit of origin, where she is an internist, the Careggi University Hospital in Florence. She spent five weeks in our capital doing an internship at one of the centers certified as excellence in rheumatology by the European Reference NetWork (ERN) network.

Elisa speaks Portuguese almost correctly, a language she says she wanted to learn when, in 2017, she came to Portugal for Erasmus, already during her medical course. At the time, she says, she chose to stay for six months, “I was afraid of staying longer”, she confesses, of not adapting, it was a new country, a new hospital, but after a month at the Faculdade de Ciências Médicas, at Universidade Nova de Lisboa, she had already regretted not opting for a longer period, a year, “only there was nothing left to do”. Now, in the third year of her specialty, she has chosen Portugal again. He applied for an ERN internship and got it, once again, “it was very little time,” he comments laughing. “I’m really sorry to leave tomorrow.”

In one of the old amphitheaters of the Faculty of Medicine of Lisbon, in Santa Maria Hospital, Elisa meets other intern doctors, Thaís, Letícia, Teófilo and Everton, who have just arrived from Belo Horizonte, in Brazil, for an internship in the Gastroenterology service, and with which they will complete the two-year “residency in clinical medicine”, a kind of internship in general practice. Only after completing this period will they be able to take another exam to choose the specialty they will practice in the future.

Elisa Fiorentini, 29 years old, is a doctor in a hosptal in Flirenze and says that from her training in Portugal in rheumatology she took a lot of things, one of them is knowing how to ask for
Lisboa, 03/02/2023 – Elisa Fiorentini, médica italiana na unidade técnica de reumatologia no Hospital de Santa Maria onde está a complementar a especialidade. Existe um número crescente de médicos estrangeiros que escolhem este hospital e a Faculdade de medicina para completarem os seus estudos.
Elisa Fiorentini, 29 years old, is a doctor in a hosptal in Flirenze and says that from her training in Portugal in rheumatology she took a lot of things, one of them is knowing how to ask for

Elisa is leaving, but she doesn’t rule out the possibility of returning someday. “This project ends here, but I never say no. Since my Erasmus experience, I’ve learned to lose my fear of something I don’t know. I had a good experience then. And now too. I was very well received.”

The other fellow doctors are just starting their training, but after three days they are already wondering if “the Revalida will be very difficult” – that is, the equivalence of their medical courses in Portugal. The five are examples of many other interns who, at this time of the year, arrive at the Centro Hospitalar Universitário Lisboa Norte to do training in various services.

Some come under the umbrella of international organizations, such as the European Reference NetWork, others arrive through protocols and direct partnerships with foreign hospital services. But the choice is up to each one, and everyone agrees that the most important thing in this type of training is to be done in a service with “international referral” and with “renowned professionals”.

In the case of the Brazilian doctors, they all came without being under agreements between hospitals. “We researched the Santa Maria gastro service, because it is very complete; besides the ward, it also has the technical procedures and exams component, and in Brazil these are rarely done by gastroenterologists, and this is very important for us,” they explain.

How important it is also to be able to realize the goal of experiencing the practice of medicine in a different country. “More and more, knowledge cannot be restricted, especially for young doctors. The theory is the same for everyone who graduates from medical school, but the practice is different, and that’s what we want to see here,” argues Everton Rodrigues.

After five weeks, Elisa Fiorentini talks about her experience and confesses: “I take a lot away from here. At the time of Eramus she was encouraged to leave Italy by two friends, who were determined to enter this program and who made her think: “What do I do? Do I stay here alone, or do I take a risk too?” she decided to take the risk. Now she has also been encouraged by the head of her service to go out and deepen her knowledge.

“I wanted an internationally recognized service with expertise in rare diseases, because rheumatology has many rare diseases and each center has its patients. For example, the rheumatology center in my hospital treats many diseases, but it is very focused on systemic sclerosis, and I wanted to be in a larger center to be able to observe other diseases and how to deal with them, and the Santa Maria service had that,” he explains.

The Italian doctor assumes that one of the most important things she observed in the Portuguese service was the multidisciplinary consultations. “There are many. Rheumatology diseases are not just about joints, they are about many others, even the autoimmune kind, and multidisciplinary consultations end up being very important to get a global view of the patient, the view of other specialists. Sometimes, only when you look at a problem from several angles do you understand what the solution is. Otherwise, each specialist only sees his or her small part and that doesn’t allow for a good diagnosis or good disease management,” he argues.

Elisa even says that this was the first objective that brought her here. For this reason, she reinforces with satisfaction, “I take away a lot. More knowledge about some diseases, which I see less of in my hospital, and above all to have realized when support from another specialist is necessary and to know how to ask for help when your knowledge is no longer sufficient. This is something that all doctors should experience and do, because more and more nobody can know everything about every disease.

Another thing he won’t neglect “is that I know that this center works this way and if in the future I need any advice I also know that I can count on people and on the exchange of information, knowledge and experience.

“More and more, knowledge cannot be restricted, especially for young doctors. The theory is the same for everyone who graduates from medical school, but the practice is different, and that’s what we want to see here.”

The Brazilian colleagues agree, even saying that this was also one of the reasons that brought them to a hospital service outside Brazil. Thaís Costa, 27 years old, graduated in the PUC of Minas Gerais, Pontifical Catholic University, is already sure that “gastroenterology is her specialty. Letícia Martins, 28, graduated from the Barbacena College of Medicine, also a city in Minas Gerais, is in doubt. “Actually, I had it in mind that it was gastro that I wanted to do, but then during residency I started to realize that what I like most is caring, dealing and communicating with the patient, and I’ve been thinking about the specialty of geriatrics. I know that in Portugal it’s not a specialty, but in Brazil it is and there are many doctors,” but that didn’t stop her from wanting to get to know in the gastro area what she says is “the practice of another medicine.

Thaís and Letícia confess that what impressed them most in the first days was the fact that the interns here start to learn how to do exams right away, because in Brazil this is not the case.
Thaís and Letícia confess that what impressed them most in the first days was the fact that the interns here start to learn how to do exams right away, because in Brazil this is not the case.(Reinaldo Rodrigues/Global Imagens)

Both practice in the same public hospital, Santa Casa da Misericórdia de Belo Horizonte, and both recognize that they were very encouraged by their “boss to do this optional month at the end of their residency abroad. He always tells us that it is very important to have experiences with other medicines, to see what is done differently. We found out that the Santa Maria service is very strong in this area and we applied for the internship, sending a resume and motivation letter, and we got it,” says Letícia. For Thais, one of the aspects that led her to choose the Santa Maria service was the fact that its director, Rui Tato Marinho (now clinical director of the hospital) is a specialist in hepatitis and the fact that it is a very complete service, with “wards and examination units, endoscopy procedures.

Too many working hours is a complaint in Brazil, Italy and Portugal

After three days, Thaís says that what impressed her most was that the interns on the service could handle the exam techniques (endoscopy and colonoscopy) from the first year of the specialty. “They learn all kinds of procedures right away; in Brazil it’s not like that. When we enter the specialty, we do two years, but if we want to do technical procedures we have to do two more years, because it is another specialty.” Letícia agrees that this is one of the big differences in relation to the specific training in her country. “What we have already noticed is that here the procedures or exams are very restricted to gastro doctors. There, a general surgeon can do the two years of endoscopy and become an endoscopist. It is a specialty apart”.

But there is more. Thais points out that, “although the ward routine is very similar to ours, the interns don’t stay only with the ward work, they circulate a lot. They go to the doctor’s office, do the emergency room and also technical procedures. It’s a more varied job. For now, the idea that they have “is that here there is more quality of life for doctors and that the way of thinking is different. In Brazil, we can’t complain about medical unemployment, but our work is more devalued and the amount of working hours is much greater. The five laugh, because this is one of the complaints everywhere. Whether in Brazil, Portugal or Italy, “we are also very similar,” says Elisa.

Teófilo already knows that gastro is what he wants to do as a specialty, and he is thinking about both hepatology and imaging.
Teófilo already knows that gastro is what he wants to do as a specialty, and he is thinking about both hepatology and imaging.(Reinaldo Rodrigues/Global Imagens)

Teófilo Bom Conselho is the youngest of them all. He is 25 years old, the being a doctor has always been a childhood dream, even though in the family there is not a single doctor. “Ever since I can remember I said I wanted to be a doctor. It was a very difficult path, a lot of preparation, because medicine is one of the most competitive courses and with the highest grades to get into college. I entered when I was 17 years old. I did the six years of coursework and graduated in 2020. At the beginning of 2021, I started medical residency, which I finish at the end of February.

Then his path will be to go to São Paulo, where he wants to do the gastro specialty, about which he also has no doubts. “It’s what I want. It was very well defined for me during residency, because at the beginning cardiology was also an option”, confessing that his coming to Portugal was also encouraged by his colleague Everton. “I had everything prepared to do this internship at the University of São Paulo, which is one of the best in Brazil, but Everton got the internship here and ended up encouraging me to apply. And I came, I couldn’t miss the opportunity to get to know a different medicine”.

Teófilo and Everton both work at the Dr. Celio Castro Metropolitan Hospital in Belo Horizonte, a very new facility, purpose-built in 2015 to “respond to the population with access to public service.” Everton explains that “it is a different hospital from all the other public hospitals in Belo Horizonte.” This is because “it is a Public Private Partnership, it is a public hospital managed by the private and then it has an incredible structure and the functionality is huge. The response is very fast and very fluid”, but it is a hospital centered in the area of “Internal Medicine, General Surgery, Intensive Medicine and Neurology. It doesn’t have a gastro and I’m also going to have to leave. His future will also involve another hospital and another city, certainly São Paulo.

Everton Rodrigues already wonders after a few days if the revalidation of his diploma in Portugal will be difficult. He wouldn't mind starting to emigrate little by little.
Everton Rodrigues already wonders after a few days if the revalidation of his diploma in Portugal will be difficult. He wouldn’t mind starting to emigrate little by little.(Reinaldo Rodrigues/Global Imagens)

But both confess that they are going with an “open mind”. Teófilo says he is thinking more about hepatology, but is also looking at the option of imaging, knowing that the latter is the one that brings in the most money, although, he says, “hepatology can also do it, if I manage to get into a transplant team.

Everton, 26 years old, says he likes “more the imaging part, the procedures, but I’m also passionate about the clinical part, I like to deal with people, but I’m 60% inclined to imaging and 40% to clinical. Being a doctor “is also part of the early days of my existence, although it was also a distant thing, because in my family there isn’t a single doctor, I’m the first. I’ve always liked people, I feel good about caring, and I couldn’t see myself doing anything else”. For Everton, leaving Brazil after the specialty is also an option. “I’m so delighted that I wouldn’t have any impediment to come back and try the revalidation, to be able to start emigrating little by little.”

For the five young doctors, knowledge in medicine is universal and they all maintain that “the value of life is equal for everyone. Therefore, “everyone should have access to health care in the same way. A patient is a patient, the disease is not different because he is poor or rich,” Elisa sustains, arguing that for her, in terms of the future, the most important thing would be for the States to invest more in health care in the public system. “In Italy, as in Portugal the private part of health care is gaining as much strength as the public part, and so Health Care is no longer accessible to everyone in the same way.”

In the future, Teófilo says he would like Health to be more valued in Brazil. “The theory is very good, but in practice there is a lack of investment at all levels, municipal, district, and state. For Everton, there are two things that would make a difference, “one is that health resources should be destined more to prevention than to the treatment of disease, and the other is that, regardless of all the technological development, the art of caring with one’s hands, of dealing with people, should not be lost”.

Around here, interns did not want to fill 161 vacancies

In 2022, 2057 vacancies for specialty internships were launched, starting in 2023. It was the largest number ever, said the Ministry of Health, but this increase also recorded the largest number of vacancies ever to be filled, 161. Of these, 90 were in the hospital career and 71 in primary care. Of the total number of candidates in the contest, 438 refused any of the vacancies. The specialties most affected were Internal Medicine, General Practice, Clinical Pharmacology, Immunohemotherapy, Clinical Pathology and Public Health. The Centro Hospitalar Universitário Lisboa Norte received 210 interns in January, 95 for a specialty and 115 for general training.

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