Doctors in the making, or degrees for sale? A student's view of Brazil's medical education crisis

Introduction: Historical Background and Expansion of Medical Schools Medical education in Brazil dates back to the 19th century and was developed under strong European influence, characterized by a hospital-centered, technocratic model that primarily served the urban elite(1). Since its origins, medical training has been concentrated in major urban centers and traditional institutions, consolidating a centralized and selective system with limited engagement with the country's territorial and social diversity(2,3). As a direct consequence of the Brazilian Health Reform, the creation of the Unified Health System (SUS) in 1988(4) introduced a new vision: to train physicians with a generalist profile, focused on primary care, territorially integrated, and socially committed. This profile, later incorporated into the National Curricular Guidelines for the Undergraduate Medicine Course(5), explicitly began to guide medical training in the country, establishing that graduates must act in an ethical, humanistic and socially responsible manner, with the ability to address the health needs of the population in different contexts and levels of care. Beginning in the mid-2000s, Brazil experienced a steady expansion of undergraduate medical education. Acceleration occurred after 2013 with the enactment of the Ministry of Health's "Mais Médicos" Program(6–9). Between 2014 and 2024, dozens of new medical schools were authorized and thousands of new seats opened. A large portion of these new seats was allocated to private institutions, and many were added to existing programs rather than newly created ones(3,10). This policy-driven growth, absorbed largely by the private sector, coincided with consolidation among major educational groups, uneven regional distribution, and constraints on infrastructure and supervised practice(3,7,11). These dynamics define the accelerating phase that frames our analysis in the following sections. Drawing on our close observation of this transformation, we affirm that this vision has been increasingly challenged by an uncoordinated and accelerated expansion, evolving into a complex and fragmented process. It has been shaped by interiorization efforts, the surge of private institutions, the concentration of admissions in educational conglomerates, legal and political controversies, and a progressive decline in the competitiveness of admission processes(2). Paradoxically, this decline has unfolded alongside a marked increase in the pursuit of medical careers, a dynamic that has fueled the proliferation of new institutions while simultaneously eroding admission standards. The landscape of medical education in Brazil thus presents unique challenges and opportunities capable of significantly shaping the academic and professional trajectories of future physicians. In this context, it is essential to cultivate a critical mass of students capable of analyzing, in a reflective and proactive manner, the reality in which they are embedded and considering its impact on professional practice. This opinion article offers an evidence-based analysis of the expansion of medical schools in Brazil, drawing on the authors' experience in medical education to describe the challenges faced, examine possible reforms, and highlight the forces that still drive the pursuit of excellence. Expansion of Medical Schools and Inequality in the Distribution of Medical School Seats As previously detailed in other publications, the acceleration of medical-school expansion after 2013 was catalyzed by the Ministry of Health's "Mais Médicos" Program(6,8,9), a health policy established by Law No. 12.871/2013 that integrates provision, training, and regulation. This policy context frames the analysis of how new seats and schools were distributed and how regional inequalities evolved during the 2014–2024 scale-up. The quantitative expansion of medical schools in the country has not been accompanied by equivalent qualitative improvements, a fact evidenced by the Medical Demography in Brazil 2025 report(11). On the contrary, this growth triggered significant changes in the profile of students and faculty, raising concerns about the future of the medical profession. From our perspective, this is not merely a numerical issue, but rather a structural transformation whose social, ethical, and educational consequences remain unresolved and under-discussed. In the past ten years, the number of medical schools rose from 252 to 448, with nearly 28,000 new seats authorized(10). This is almost four times the number registered between 2004 and 2013. The turning point was the enactment of Law No. 12.871/2013, which created the "Mais Médicos" Program(6,8,9). Conceived as a Ministry of Health public policy, it integrates health and education dimensions through three axes: provision (deploying physicians to underserved and remote areas), training (expanding supervised practice opportunities), and regulation (criteria for authorizing new schools). While its aim was to mitigate regional inequalities, the policy's implementation was predominantly absorbed by the private sector and concentrated in already privileged regions(10), which limited its potential to achieve a more equitable distribution of physicians across the country. More than 91% of the new seats created since 2014 were allocated to private institutions, which by 2024 accounted for almost 80% of all undergraduate medical seats in the country (Figure 1A–C). This privatization of access has deepened territorial inequalities. While the Southeast region holds over 41% of seats, particularly in São Paulo and Minas Gerais, as a result, states such as Roraima, Acre, and Amapá account for just 1% of the national total(10,11). It is evident that the so-called interiorization has occurred more on paper than in practice. Nearly 40% of the new seats were added to existing programs, often without proportional investment in infrastructure, supervision, or internship sites, as reported by Andrade et al.(10) and reinforced by the Federal Council of Medicine in its 2024 technical note highlighting deficiencies in newly accredited schools(12). As a result, students face overcrowded classrooms, limited access to practical training, and weakened pedagogical follow-up. In addition to infrastructure constraints, rapid expansion increased class sizes and student-faculty ratios at many institutions(2,10). National analyses during the expansion period report signs of academic decline, coinciding with the accelerated growth of for-profit schools, a pattern consistent with resource dilution and reduced opportunities for supervised practice(10). Although causality cannot be firmly established from observational data and from the authors' experience in medical education, warnings from the Federal Council of Medicine about insufficient infrastructure and supervision at newly accredited schools reinforce this concern(12,13). From a social equity standpoint, the predominance of private-sector seats shifts a substantial share of training costs to households through high tuition fees, increasing debt burdens and potentially narrowing access for lower-income and minority students(2,14,15). Given the spatial concentration of programs in wealthier regions, these financial barriers compound regional disparities in entry, persistence, and graduation(10,11). Without targeted scholarships, social quotas, and student support services, expansion risks amplifying the very inequities it sought to reduce(14,15). From our perspective, this scenario is incompatible with the humanistic and socially responsive training required by the SUS model and advocated by the National Curricular Guidelines for the Undergraduate Medicine Course(5). This uneven expansion, predominantly led by private institutions, is graphically illustrated in the distribution of seats and their concentration across regions (Figure 1A–C). These patterns set the stage for understanding the persistent inequalities in the medical workforce, which will be discussed in the next section. Publicly traded universities, in turn, have treated medical education as a financial asset(2). The commodification of the medical degree, once a symbol of public service and ethical responsibility, now serves market interests. In this context, training of future physicians risks becoming a business model rather than a societal mission. These concerns are not isolated. In 2024, the Federal Council of Medicine (CFM) issued formal warnings regarding infrastructure deficiencies and supervision failures among rapidly growing institutions(12). We believe we are witnessing a crisis of meaning. What does it truly mean to train physicians today in Brazil? Are we producing professionals or merely degrees? Rather than rejecting expansion altogether, we advocate for a more regulated, strategic, and socially aligned growth. The issue is not in the number of seats but in the lack of direction. A country with continental dimensions like Brazil cannot afford to neglect the quality, equity, and purpose of its medical education. Profile and Distribution of Physicians in the Post-Expansion Era The expansion of medical education in Brazil has undoubtedly reshaped the demographic composition of the medical workforce. However, we argue that its practical impact on the healthcare system remains limited and, in many ways, problematic. As of 2024, the Southeast region concentrated 55.5% of the country's physicians, while the North accounted for only 4.7%(11) (Figure 1D). These numbers reflect deep-rooted territorial inequalities that the simple increase in training vacancies has not been able to overcome. Although the national average stands at 2.81 physicians per 1,000 inhabitants, this figure masks stark regional disparities, as shown in the distribution of physicians across the national territory (Figure 1D–E). In Amazonas, for example, the ratio drops to 1.34, while the Federal District reaches 6.29 physicians per 1,000 inhabitants(11) (Figure 1E). These differences expose territorial inequities and challenge the notion that simply training more physicians will ensure broader access to care. This imbalance is exacerbated by the growing influx of young physicians into the labor market. Professionals under the age of 34 now comprise about one-third of the active workforce(11). A large proportion are graduates of private institutions and tend to remain concentrated in major urban centers, where saturation is becoming increasingly evident. In parallel, the profession is undergoing a visible process of feminization(11). Women already constitute the majority among physicians aged 29 and under, accounting for 62.6% of this group(11). While these generational and gender shifts represent important changes in the profession's profile, they have not, by themselves, reduced gaps in underserved regions or improved working conditions for new physicians, which depend on structural policies and adequate incentives. The sharp increase in the number of young professionals with limited clinical experience has revealed a set of structural problems documented in recent analyses. These include precarious employment and contractual instability, as highlighted in the Medical Demography in Brazil 2025 report(11), the saturation of opportunities in major urban centers(11), and the persistent shortage of medical residency positions relative to the number of graduates(16). Such conditions, as emphasized by Barbosa et al.(16), undermine the professional development of young physicians and expose systemic fragilities that cannot be overlooked. Taken together, these factors indicate a growing misalignment between the place of training, the place of practice, and the long-term prospects for integration into the public healthcare system. Experiences from other Global South nations reveal similar challenges. In South Africa, for instance, the expansion of medical education has been accompanied by persistent inequalities in distribution, infrastructure, and retention of physicians in underserved areas(17). Comparable dynamics have also been described in Latin America. In Mexico, annual production of physicians outpaces the number of newly licensed specialists and persists alongside regional maldistribution(18). In Colombia, rapid growth in medical programs since the 1990s has raised concerns about quality and accreditation, while residency capacity remains limited (19–21). These patterns mirror global analyses showing that medical school proliferation can outpace the development of robust accreditation frameworks, with implications for equitable workforce integration(22). Over the past two decades, Brazil has experienced a rapid expansion in medical education; however, growth in accredited residency positions and stable employment has not kept pace(2,10). This imbalance has contributed to localized oversupply in major urban centers, underemployment, and concerns about declining returns to training, as the number of graduates increasingly exceeds the absorption capacity of the health system(11,16). Here, market oversaturation denotes a structural mismatch in which the annual number of medical graduates outpaces the availability of residency positions and stable employment, producing local oversupply in large metropolitan areas despite national or regional shortages(23). In Brazil, this pattern is evident in the widening student-to-resident gap (Figure 1B) and in stark gradients in physician density per 1,000 inhabitants (Figure 1D– E), indicating urban saturation alongside peripheral scarcity(11). Similar dynamics have been reported in Mexico, where physician density coexists with regional maldistribution and bottlenecks in specialist training(18), and in Colombia, where rapid growth in medical programs has outpaced uniform accreditation and residency capacity(19–21). If medicine follows this trajectory, the result could be a continuous production of graduates without ensuring their integration into the healthcare system in a qualified and equitable manner. This scenario risks not only the waste of human capital and public investment in education but also a deterioration in working conditions, the erosion of professional value, and the weakening of public healthcare delivery, ultimately undermining both the financial stability and the long-term career prospects of physicians. Expansion and Gaps in Postgraduate Training Securing a spot in a medical residency has become one of the most formidable hurdles in the professional journey of newly graduated physicians. The number of graduates already exceeds the number of available positions, revealing a critical mismatch between the volume of medical training and the system's real capacity to absorb these professionals(11) (Figure 1A–B). This misalignment is not only evident in national statistics but has also been highlighted by the Pan American Health Organization, which estimates that fourteen countries in the Americas, including Brazil, may face a shortage of up to two million healthcare workers by 2030 if structural reforms are not implemented(24). Despite this projected deficit, training programs located in prestigious urban centers continue to attract intense competition, while strategic specialties such as family and community medicine, particularly in underserved areas, struggle to fill available positions, although it is an essential specialty within the SUS and has a growing number of authorized positions(25,26). This imbalance reflects a structural disconnect between the type of specialists being trained and the country's actual healthcare demands. 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