Apresentação no SHM2019, Washigton, EUA.

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 they’re 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 I’m 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 group’s 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 don’t have it. It’s a
physician [usually young, usually woman] that restricts her work to emergent / urgent /
bureaucratic needs of inpatients when the “owner” is not present. And he’s 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 don’t 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 it’s 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
* Florianópolis
* 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 São 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 (Florianópolis) 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 Providência
* 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 ward’s multidisciplinary team.

26. And you are invited to visit us!
Twitter@brhospitalist
gbbarcellos@gmail.com