Significance of Hiring Strategies: Lessons from Critical Care and Emergency Services in Brazil

Intensive care units and emergency departments necessitate highly skilled physicians with expertise in managing critically ill patients. In Brazil, medical management firms provide hospitals the opportunity to outsource their medical personnel in critical sectors. Although this appears to be a convenient and pragmatic answer, it presents numerous ethical concerns that are challenging to address. This article examines insights gained from Brazil that can be emulated, particularly in emerging nations.

Introduction

Brazil is a growing nation facing significant challenges in its public and private healthcare systems. Throughout the COVID-19 epidemic, it was evident that Brazilian Intensive Care Units had a mortality rate for intubated patients that was at least double that of developed nations (Ranzani et al. 2021). Moreover, emergency services at public hospitals are often highlighted in the media for their inefficiency and failure to provide humane care, compounded by persistent overcrowding (Matoso 2014). The resource deficiency is both technological and material; however, it primarily concerns human resources (Batista Filho et al. 2022). In Brazil, there is a shortage of highly qualified personnel in emergency and critical care services due to the minimal qualification requirements in these industries. Specialisation in emergency or critical care is not a prerequisite for employment in the emergency and critical care departments of most hospitals in the country, compounded by a markedly unequal distribution of these scarce specialists throughout Brazil (AMIB 2025). Nonetheless, an additional issue persists in Brazil's healthcare system: the recruitment process for the many physicians employed in hospitals. Presently, in Brazil, and especially in São Paulo, the predominant number of hospitals employ outsourced firms to staff their shifts, frequently resulting in multiple organisations operating within the same facility. This management style has numerous, seldom addressed, and significantly adverse effects on healthcare facilities, the professionals engaged, and, particularly, on patients.

Rationale Behind Brazilian Hospitals Employing Firms for Medical Staffing

It is common for major hospitals across all Brazilian states to contract businesses to manage their on-call schedules in various departments. This choice is supported by multiple justifications. These facilities frequently require extensive staffing to accommodate numerous shifts, and utilising these organisations for physician recruitment significantly simplifies the process. Nonetheless, there exists an obscure rationale, seldom addressed, that pertains to money matters. Hospitals are reluctant to incur the costs of hiring an expert physician. Utilising a third-party firm for professional recruitment mitigates the hospital's risk of future labour litigation, as the firm is deemed "responsible" for the professional. The CLT (consolidated labour law) hiring paradigm, the primary framework for employment in the country, is circumvented, and the physician is engaged as a "partner" by the organisation. These are generally contracts for "Sociedade em Contas de Participação" (silent partnership) or "Sociedade Limitada" (private limited company). In this model, the physician is designated as a partner possessing a fractional ownership in the company (less than 0.5%), hence lacking labour rights, in contrast to the provisions of the CLT hiring model. This constitutes a blatant misrepresentation of medical practice, aimed explicitly at evading taxes and fulfilling labour rights obligations (Martins 2021). Despite being unequivocally banned under the Brazilian Constitution, several labour law perspectives regard this recruiting model as a leniency in labour regulations that advantages both employers and employees (Matsumoto and Ferracini 2025). This perspective is constrained and fails to represent reality, as the consequences are far more profound than they appear. This concept not only reduces expenses but also streamlines the hiring and dismissal of physicians by circumventing labour rights considerations. The relationship with the company consists solely of an entry and a leave, devoid of any rights for the professionals involved. The bulk of physicians employed by these companies lack experience and do not completely comprehend the extent of the contracts they are endorsing. They seek employment and prompt remuneration for their labour. Numerous professionals possess debts acquired to finance their medical education and often lack a comprehensive understanding of these obligations.

Medical Management Businesses and Their Operational Framework

These entities identify themselves as "managers" of emergency departments, intensive care units, and hospital wards. The overwhelming majority provide only shift coverage and have minimal impact on management. They engage in direct negotiations with hospital administrators and appropriate a significant portion of the physicians' remuneration. Generally, they attempt to market the "management" of a certain hospital sector; however, managing a sector in isolation yields no advantages for the institution, as the sectors are interdependent (Batista Filho et al. 2024). Sectors that fail to collaborate cannot alleviate congestion in other areas, thus exacerbating the burden on those sectors. In hospitals, it is prevalent for each company to operate as an independent entity, exhibiting minimal collaboration with sectors managed by competing firms. Companies frequently seek to acquire their competitor's market share whilst simultaneously aiming to undermine the performance of adjacent sectors to compel the rival firm to exit the market. Collaboration between sectors is infrequent when distinct organisations manage different sectors within the same hospital.

The proliferation of "management" businesses engenders inherent competition amongst them, resulting in a contest to determine which can best satisfy client preferences. Quality indicators must consistently be exemplary, as subpar statistics allow competing firms to position themselves as viable alternatives. In Brazil, hospital quality departments are frequently minimal, comprising one or two personnel. This benefits these companies, which frequently provide "assistance" to the people in these departments in formulating statistics that do not reflect reality. The local leader designated by these organisations typically fulfils this duty whilst also ensuring that the employed physicians are tailored to meet the hospital's specific requirements. This is typically a more seasoned physician with several years of tenure in the organisation, appointed as a medical coordinator for the firm.

In the paradigm developed by outsourced firms, the physician who assists patients has limited autonomy. It is imperative to concentrate on the client rather than the patient, as previously said. Physicians will be compensated for conforming to these logistics rather than for assisting patients. If they fail to adjust to this reality, the corporation reserves the right to terminate their employment, so concluding the aforementioned "partnership" (equivalent to a dismissal) (Sindicato dos Médicos do Ceará 2025). Despite any unfairness in this firing or any abuse in this exchange, the professional has limited recourse options, as their relationship was inaccurately characterised as a partnership rather than employment, thereby precluding any legal labour rights. To initiate any legal protest, it is imperative to substantiate in court the existence of an employment relationship, which would entail significant inconvenience and stress, as well as the potential for reprisal from the defendant corporation. It is crucial to acknowledge that it is exceedingly challenging for physicians to decline this hiring approach, as nearly all hospitals employ it.

The primary goal of these organisations is to focus on the customer, specifically the hospital administration. The emphasis is not on the patient. Consequently, circumstances that harm the patient and could tarnish the hospital's reputation are often suppressed to avoid consumer dissatisfaction.

Impact of Existing Recruitment Approach on Doctor-Patient and Doctor-Doctor Interaction

Outsourced firms have dominated the interaction between physicians and medical institutions. Consequently, hospitals frequently lack awareness of which professional is assigned to duty on any one day. The connection has been strained since the healthcare institution has consistently negotiated with the company's local representative. The doctor may be dismissed at any time, in accordance with the interests of the client and the company, thereby nullifying the illusory partnership established in the contract, which is intended solely to relieve both parties of the labour costs associated with conventional hiring (Brazilian Government Official Website 2025).

The physician, conversely, recognises that he may be dismissed at any moment. Consequently, he lacks a link with the institution where he is employed, which subsequently diminishes his rapport with the patients. The physician's interaction centres on the contracted firm engaged and on the particular shift he assumed with the organisation. Numerous physicians will work each day, every week at various hospitals and in different organisations. The sole objective of the physicians engaged is to fulfil the shift and receive compensation for that day. There is an absence of horizontal integration in care, as well as a lack of affiliation with the institution where the work is conducted. Certain hospitals employ personnel through CLT and outsourced organisations in the same medical team. Generally, a poor relationship exists between outsourced physicians and those employed under the CLT, as the latter are aware that the hospital may seek to terminate their positions to cut expenses, substituting them with the former. This engenders a detrimental, cyclical pattern across all institutional connections, resulting in clear losses for all parties concerned. From a strictly financial perspective, the sole beneficiaries are the corporations and the medical institutions. Whilst numerous individuals promote the terms' managerial' and 'medical quality', these are not the primary objectives.

Outsourced Corporations and Ensuring Quality Care

The disparity between practices in esteemed institutions and those in hospitals dependent on these companies is substantial. All premier healthcare facilities cultivate partnerships with professionals who have extensive training, which takes years to attain. These professionals frequently command higher fees and favour superior employment circumstances. Given that the primary objective of outsourced organisations is not to deliver quality, collaborating with these individuals is not a priority. Nonetheless, a facade of technical quality is essential as a marketing instrument. In this regard, these companies frequently own continuing education departments that offer brief courses on specialised subjects such as orotracheal intubation or anaesthesia. Major corporations offer one-day seminars on cardiopulmonary resuscitation and doctor-patient communication. Such activities are frequently promoted on social media and in emails to communicate a notion of superior care. Nonetheless, these classes significantly fail to produce a meaningful effect on the medical education of novice practitioners. The effect is minimal and contributes little to altering daily medical practice, functioning more as a marketing strategy than as substantive medical education. For laypersons and other non-experts, there is a prevailing perception that high-quality care is being delivered, which benefits corporate marketing and facilitates the establishment of new contracts with hospitals.

A prevalent way to demonstrate dedication to quality is to implement specific measures to set standards and standardise care. Such endeavours are typically focused on particular instances, sometimes linked to hospital accreditation. At this juncture, the corporation often undertakes an organisational initiative, consistently aimed at satisfying its client, the hospital, and obtaining accreditation.

There are instances in which the outsourced firm is employed by another entity to which the municipality or the federal government has delegated the management of a hospital. These are healthcare organisations that engage businesses to oversee medical shift management.

The owners of these enterprises are frequently highly credentialed physicians who have identified a lucrative niche through their associations with hospital owners and executives. They have amassed a fortune through their commercial transactions with these healthcare organisations. Certain individuals possess significant influence and occupy roles within medical regulatory organisations.

Depersonalisation of Physicians Inside Healthcare Institutions

Employees in these organisations have diminished autonomy and are perceived as disposable within the institution. Despite their technical proficiency, their actions will only be esteemed by the firm if they align with corporate policy, which contradicts the oath taken by doctors upon graduating from medical school. A professional who conceals the hospital's issues and minimises client inconvenience is preferred. Conversely, the overwhelming majority lack sufficient training for their current roles and would be unable to qualify for comparable positions in a prestigious hospital. Consequently, they ultimately acquiesce to substandard working conditions and recruitment practices. Emergency departments and intensive care units in Brazil are managed by physicians lacking training in Critical Care or Emergency Medicine. These less skilled physicians are often "absorbed" by this economic logic, readily conforming to the requirements of management firms. They are promptly substituted by other physicians if deemed unsuitable for the current programme. These firms invite more qualified professionals to assume elevated positions within the hierarchy; yet they are conditioned to prioritise the customer over the patient. Individuals who embrace the organisation's concept and adhere to its rationale typically advance within the hierarchy. The rationale is to advance individuals who garner favour with hospital administration and management firms, rather than those who provide superior patient care. Highly qualified specialists who fail to adapt to these logistics become adversaries, as they ultimately identify deficiencies in treatment and administration, troubling the owners of firms and hospitals. Some are designated to oversee the work of less trained physicians, frequently serving as the sole qualified professionals amid numerous other doctors in an emergency room or ICU. Management of corporations and hospitals conceals procedural failures and the failure to recognise severe cases, even when these lead to adverse patient outcomes. Meetings convene to examine failures, though they seldom address the underlying issue; instead, they focus on superficial expressions of individual shortcomings or on generating additional documentation for the daily routine. When concealing a significant failure is unfeasible, this inadequately qualified physician is substituted by another of comparable competence, who is likely to commit analogous errors. The main goal is to avoid compromising the organisation or hospital's integrity.

This approach results in the total depersonalisation of the physician, rendering them expendable and disheartened (Paraizo et al. 2020). His sole focus lies in fulfilling his hours and receiving his income, whilst the quality of service is relegated to a secondary position.

Factors Contributing to Challenges in Transforming the Brazilian Healthcare System

Altering the healthcare reality in Brazil is exceedingly challenging. The primary reason is that the general public and the media are unable to recognise the harm inflicted by this hiring paradigm. The consequences of this business logic can only be evaluated by other professionals engaged in the process. For many, the mere presence of a physician in an intensive care unit or emergency room suffices, and they fail to comprehend the systemic implications of the described reality. Distinguishing between genuinely qualified specialists and untrained individuals is particularly challenging for those outside the field, especially since, in Brazil, the general population does not recognise critical care and emergency specialisations as legitimate medical disciplines, a reality already common in developed countries. Politicians also fail to comprehend these consequences, and the overwhelming majority of physicians hesitate to raise concerns out of fear of litigation. A multitude of lives are forfeited due to insufficient specialised treatment and the disengagement of experts who are disheartened from doing their vocation with excellence. The errors committed are nuances that elude the comprehension of most of the general population, yet are evident to specialists in the domain, primarily concerning the failure to acknowledge and address critical cases that necessitate prompt intervention for a chance of survival. Deficiencies in protocols for catheter placement, intubation, and mechanical ventilation management are a prevalent concern.

Managing a Business Without Compromising Medical Integrity

In Brazil, there exist companies that provide sufficient support in critical care and emergency departments. These enterprises employ highly qualified physicians, although they are confined to private or academic medical institutions. In these instances, the hiring standards are significantly elevated, as hospitals require superior care, either because they have more skilled personnel or because they cater to more discerning patients. Major corporations also recognise this disparity and endeavour to assign more qualified personnel to higher-demand hospitals. Professional remuneration must be calibrated according to the level of training, emphasising the necessity of intensive care physicians in the ICU and emergency physicians in the Emergency Room. The aforementioned corporations seldom distinguish between professions, compensating both those without specialised training and highly trained physicians equally. Moreover, it is imperative that the government formulate explicit regulations governing physician recruitment in Brazil. The strategy of utilising legal loopholes to reduce the costs of hiring specialists adversely affects all parties involved, including patients. Transforming physicians into "partners" poses greater risks to public health than it appears.

The Brazilian Intensive Care Association reports a deficit of over 30,000 specialist intensive care physicians in Brazil (Martins 2021). Consequently, it is unavoidable to use fewer skilled people to satisfy the entire demand. The deficiency of intensive care physicians is a worldwide issue, impacting nations including the United States of America (Halpern et al. 2016). Nonetheless, the existence of these physicians is not a genuine necessity for corporations and hospitals in Brazil, which opt to compensate lower-qualified personnel at lower rates. The general populace understands the need for a cardiologist, but lacks understanding of the roles of an intensive care or emergency physician. Notwithstanding this, it is crucial to reform the hiring practices for these specialists, eschewing the subcontracting paradigm.

Concluding Reflections: A Reality That Must Be Transcended

A silent catastrophe is occurring in Brazil. It is imperative to transcend this management style to facilitate the evolution of the country's health system. Numerous individuals are succumbing to or enduring irreversible harm from this antiquated and detrimental approach, which benefits only unscrupulous entrepreneurs. Brazil exemplifies the discord between medicine and business interests, demonstrating that a favourable financial outcome for a company can be achieved at the expense of patients and healthcare professionals. This is not intended to vilify businesspeople and entrepreneurs, but to advocate for a cultural transformation in Brazilian healthcare that prioritises quality over profit at any cost. It is essential to empower physicians and insist on high-quality care from them. This method is unfeasible if the populace is unaware that they receive significantly less assistance than they are entitled to. It is essential for each healthcare field to have specialised professionals. Major healthcare institutions in developed countries exercise considerable caution in their employment practices and would never adopt a hiring approach exclusively designed to enable potential layoffs and enhance profitability, as observed in Brazil. This unseemly hiring strategy ultimately affects patients, who are the sole justification for hospitals' existence. It is noteworthy that less efficient treatments incur higher costs, as evidenced by the annual 20% increase in health insurance premiums in Brazil (Lopes and Levi 2025).

Conflict of Interest

None.