Discussion
Our findings indicate one in eight family and community physicians have earned a master’s degree, and little more than 1 in 40 have earned a PhD. The number of new degrees is increasing over time, and most of the degrees are in collective health (not medicine) and were obtained in the Southeast and South regions. Gender is associated with the probability of obtaining a master’s degree and, together with the mode and knowledge area of the master’s degree, also with that of obtaining a PhD degree. In comparison to family and community physicians specialising through medical residency, those specialising through certification were more likely to already have earned a master’s and/or PhD degree (instead of earning after specialisation), but just as likely to have earned their degree in medicine, collective health or other knowledge areas.
Professional master’s programmes are responsible for most of the recent increase in the number of master’s degrees, and might be attracting graduate students who would otherwise opt for academic programmes. The Northeast region, with its RENASF network of institutions offering a professional master’s programme focused on the Family Health Strategy,19 20 accounts for part of this increase, as does the state of Rio de Janeiro, whose capital city recently invested heavily in the expansion of the Family Health Strategy and incentivised health professionals to earn master’s degrees21; but the increase in professional master’s degrees was not restricted to these states (data not shown). Even though the ProfSaúde programme18 is expected to contribute to this increase, it does not account for our findings, because its first students graduated after we obtained our data.
Brazil has been promoting professional master’s degree on Family Health alongside other qualification initiatives, such as residencies, short postgraduate courses, and academic master’s degree.21 30 While one would expect any qualification to contribute something, responsible public policies for human resources in health depend on critically examining the relative benefits of the multiple possible postgraduate trajectories. For example, some qualification initiatives might add little to the performance of professionals who are already sufficiently qualified, or who are not qualified enough to benefit from said initiatives. Furthermore, for better or for worse, a professional master’s degree should increase employability in academia (even if presumably not as much as an academic master’s degree), thereby increasing workforce turnover in the Family Health Strategy while contributing to the education of the new generation of health professionals.
This debate is made even more timely by the advent of professional PhD programmes. Graduates from professional master’s courses seem to be less likely to earn PhD degrees, even after adjusting for potential confounders, such as when was the master’s degree concluded. Because graduates from professional programmes are expected to be outside academia, they might not find value in academic PhD courses. It remains to be seen if professional PhD programmes are needed to fill this niche, or if simply there’s not much use for any PhD outside academia. Meanwhile, physicians are still not required to complete a medical residency (or otherwise be certified) before working in primary care in Brazil, and posts in medical residencies lag behind the annual number of newly graduated physicians (the same applies for nurses).43
Another major finding is that most family and community physicians hold master’s and PhD degrees in collective health, not medicine. This phenomenon is more common for master’s than for PhD degrees, and for professional than for academic degrees, but it occurs in both levels and both modes of postgraduate programmes. We cannot say this came as a surprise: of the authors who are family and community physicians, all three hold a PhD in a subarea of collective health. In our experience, not only has collective health devoted substantial interest to primary healthcare as a public policy, but also the Brazilian medical community has not devoted much interest to primary care as a locus of healthcare delivery. For example, searching for (‘family medicine’ OR ‘family and community medicine’) in the SciELO Brazil collection, one of the top five journals is on medical education and the other four are journals on collective health. This suggests most research on primary healthcare in Brazil to be on health policy, service management and health promotion, as well as medical education, but not so much on clinical care.
Most medical residencies, specialist certifications, master’s and PhD degrees happened in the Southeast and South regions. The reason is twofold: these are two of the most populous regions (together with the Northeast region), and are the most economically developed ones. These facts also reflect in the overall distribution of physicians in Brazil.44 Interestingly, our data do not support a higher probability of obtaining a master’s or PhD degree for family and community physicians specialising or obtaining a master’s degree in the Southeast and South regions. This is not to say our data support equity in access to postgraduate programmes: there simply are too few family and community physicians outside the Southeast and South regions for us to make precise estimates. As the saying goes, ‘absence of evidence is not evidence of absence (of effect)’.45
On the other hand, the association of gender and postgraduate degrees was very clear: female family and community physicians are less likely to obtain master’s degrees than their male colleagues, and even less so for PhD degrees. This should not be interpreted as gender having a direct effect on educational achievement: our study was exploratory, and inclusion of gender as an explanatory variable was motivated mostly by the SAGER (Sex and Gender Equity in Research) guidelines.46 Rather, this finding should be taken as justification for further studies, aimed at a more proper explanation for this correlation. Such an explanation might have more to do with family and community medicine than with the Brazilian society at large, because half the master’s and PhD graduates in Brazil are women.47 Besides the ethical relevance of elucidating and preferably removing any gendered barriers to postgraduate education, the issue has special relevance to the discipline because most family and community physicians are women.
In interpreting our findings, one must keep in mind we depended on administrative data. Because data from Conselho Federal de Medicina (CFM; the Federal Board of Medicine) is not available to others, we could not perform record linkage to identify who had retired, emigrated or deceased. The National Registration of Specialists was expected to provide easy access to an authoritative list of physicians in any medical specialty but, unfortunately, it has not been maintained as prescribed by the More Doctors Law.48 Consequently, the number of family and community physicians is surely overestimated, even if we expect this overestimation to be minor because family and community medicine is a fairly young specialty in Brazil.44 In 2018, Augusto et al23 (using the same methods as us) estimated there would be 5,438 family and community physicians in Brazil, 276 (5%) more than the 5,162 found by Scheffer et al,44 who had access to CFM data. Another limitation of our study was that, as in Augusto et al,23 we could not include the family and community physicians who completed their medical residencies in the 1970s. SisCNRM records for family and community medicine (then community general medicine) begin at 1981, when the specialty was recognised; we can only hope family and community physicians from the 1970s eventually took the exams and were certified after 2003.
Our data had limitations concerning postgraduate programmes, as well. Postgraduate degrees will probably have been underreported to some extent, even though postgraduate students are incentivised to have a CV in the Lattes Platform and entering data on a postgraduate degree is simple enough. Furthermore, there surely was some information error in the reported degrees, but we hope to have cleaned most of those errors during our verification. One potential issue is that we verified the data using current information on the postgraduate programmes, not information from when the degrees were obtained; but much of the information is not expected to change in any significant way, and possible changes in the knowledge subarea or specialty of the postgraduate programmes would not matter for our analysis, which was done at the level of basic knowledge area. Finally, because the Lattes Platform was launched in 1999, master’s and PhD degrees earned before are expected to be underreported, even if this underreporting is expected to occur mostly among those who do not make much use of the degrees.
