ABC | Volume 111, Nº2, August 2018

Original Article Marcolino et al Satisfaction of emergency physicians Arq Bras Cardiol. 2018; 111(2):151-159 It is worth noting the high number of physicians without medical residency (31.4%) – generalists – or from medical specialties without specific training in adult cardiovascular emergency (pediatrics and gynecology). The findings of the present study show the importance of promoting continuous education programs in the region to improve the skills of the physicians working at cardiovascular emergency services. The highest satisfaction level with “ technical support” is positive in that context. In addition, such findings emphasize the need for training in emergency medicine in the medical curriculum. In Brazil, physicians graduatewithout the necessarywork experience in the emergency setting. That has been recognized by the Associação Brasileira de Educação Médica (Brazilian Association of Medical Education), which, nevertheless, reports that “most newly graduated physicians end up on work shifts at emergency units or pre-hospital care units”, but the “ Diretrizes Curriculares Nacionais” (National Curriculum Guidelines) do not value that area of medical practice. 21 The previous “ Diretrizes Curriculares Nacionais” (National Curriculum Guidelines) for medical education did not include emergency medicine in the required disciplines of the medical internship. 22 The current ones require that at least 30% of the hours of the medical internship be spent in Primary Care and Emergency Care of the Brazilian Unified Health System (SUS), “respecting the minimum of two years of internship”. 23 However, the number of hours dedicated to emergency education is still limited inmost medical schools in Brazil, 24 which tends to aggravate with the ever-increasing number of medical schools and the scarcity of practice scenarios. In 2015, emergency medicine was recognized as a medical specialty by the “ Conselho Federal de Medicina ” (Brazilian Federal Council of Medicine), the “ Conselho Nacional de Residência Médica ” (National Council of Medical Residency) and the “ Associação Brasileira de Educação Médica ” (Brazilian Association of Medical Education). Although that qualification in emergency care was being structured during the time this study was being performed, so far there is no official medical education program for pre-hospital care. Currently, emergency services face great challenges in several realms: scarcity of skilled labor, overcrowded facilities, low quality of care provided to those who most need it high turnover of professionals, and exposure of professionals to risks due to the growth of violence in large cities. 19 Several studies have assessed the organization of emergency services, but data analyzing those professionals’ satisfaction are scarce. Another study assessing the physicians’ satisfaction with the structure of cardiovascular care has been conducted in the same region, but with professionals working in primary healthcare before and after the implementation of a Telehealth system in cardiology. 16 Studies have investigated the burnout of physicians. Its frequency among emergency professionals is alarming. 25 Work dissatisfaction is one of the burnout-related factors reported. A study of 771 North American emergency physicians has observed that those reporting stress and burnout as severe problems expressed lower levels of satisfaction with their careers. 26 Another study of 193 North American emergency physicians members of the American College of Emergency Physicians, has reported that dissatisfaction related to clinical autonomy, to challenges in the emergency medicine practice and to stress were significantly associated with high levels of burnout. 27 Our study was not aimed at specifically investigating burnout in that population, but the high dissatisfaction level found indicates the need for specific assessments. This study has limitations inherent in its cross-sectional design, preventing inference of causality.Other factorsmight have affected thephysician’s satisfaction, such as professional acknowledgement, changes in salary and better working conditions, which were not directly measured in this investigation. 16 The results of the present study are important because they enable managers of pre-hospital and hospital emergency services to reflect, aiming at qualifying the care provided. Negative changes in the mental state of emergency professionals have a adverse impact on their professional performance. 28 The satisfaction with the structure of cardiovascular care of the SAMU or hospital physicians found in this study was extremely important to delineate and implement the AMI system of care. The operational flow was discussed with the managers, the tele‑electrocardiogram was installed in the ambulances and the thrombolytic was acquired, 11 however, without the adherence and motivation of the physicians and nurses at the emergency services, the AMI system of care would be doomed to failure. This is a pioneer study in the assessment of the baseline for the implementation of the AMI systemof care in Brazil, which can be a model for future implementations. Additionally the results can help the assessment of the quality of the care provided and the planning of training programs, guiding the definition of priorities, mainly for services that provide care for cardiovascular diseases. 16 Conclusion This study showed the overall dissatisfaction of emergency physicians in the Northern Region of Minas Gerais with the structure of care provided for cardiovascular emergencies. Most physicians expressed dissatisfactionwith the care provided, the structure for managing cardiovascular diseases and the technology available for diagnosis. The dissatisfaction of SAMU physicians was lower as compared to that of the emergency physicians at the regional hospitals, and the dissatisfaction of physicians of level III/IV hospitals was lower as compared to that of physicians of level II hospitals. Acknowledgments The authors are grateful for the participation of Olívia P. Loyola (Regional Superintendent of Health of Montes Claros at the time of the study), Rasivel dos Reis S. Junior (State Emergency Coordinator of the Minas Gerais State Department of Health at the time of the study), Edinardo R. Lopes (Director of CISRUN at the time of the study), Ubiratam L. Correia (Coordinator of Permanent Education of SAMUNorte), all the scholarship holders (undergraduate students nurses and physical educator) and the TNMG information technology team, which made possible the project implementation and execution of this study. Author contributions Conception and design of the research: Marcolino MS, Oliveira JAQ, Ribeiro AL, Cardoso CS; Acquisition of data: Silva GKM, Dias TD, Marino BCA, Antunes AP; Analysis and interpretation of the data: Marcolino MS, Oliveira JAQ, Silva GKM, Dias TD, Marino BCA, Antunes AP, Cardoso CS; Statistical analysis: Marcolino MS, Oliveira JAQ; Obtaining 157