Who and Where are the University of São Paulo Medical School Graduates?

OBJECTIVE: To evaluate the impact of a complex-care-based medical school in the context of the Brazilian health care system on students' career choices. METHODS: This was a retrospective cross-sectional study based on medical regulatory organization records. It included records for 7,419 physicians who graduated from FMUSP. Geographic data were analyzed using Kernel maps, and the statistical analysis was performed with SPSS® version 24.0. A p-value less than 0.05 was considered significant. RESULTS: Of the 7,419 physicians, 68.6% (95% CI 67.5-69.7) were male, and 20.7% (95% CI 19.8%-21.7%) had no medical specialty, compared to 46.4% nationwide. Internal medicine and surgery-based specialties were more popular, accounting for 39.4% (95% CI 38.3%-40.5%) and 16.8% (95% CI 15.5%-17.6%) of our study group, compared to the Brazilian averages of 25.9% and 13.5%. Our graduates also had a higher probability of staying in São Paulo City, especially when born outside the city. CONCLUSION: We believe that FMUSP remains an interesting model for studying the impact of a highly specialized center on the education and career choices of medical students.


' INTRODUCTION
The Faculdade de Medicina da Universidade de São Paulo (FMUSP) has been central to the formation of leaders in the context of the Brazilian medical system. It currently has the largest hospital complex in Latin America, and it is responsible for the graduation of 175 physicians each year, who go on to assume high-level positions in their specialties. In addition, FMUSP is known for innovation in several areas; its graduates (MDs) have been responsible for many surgical innovations, including one of the first living donor liver transplants (1), the solution for the transposition of great vessels (2) and the first successful uterine transplant (3), among many others. All of this makes FMUSP one of the 100 best medical schools in the world (4).
In Brazil, the distribution of physicians across the national territory is heterogeneous. Despite the fact that there are approximately 450,000 professionals in the country (approximately 2.18 physicians per 1000 inhabitants), they are concentrated in large Brazilian cities, such as Vitória (12.27 physicians per 1000 inhabitants). In contrast, some states such as Maranhão have 0.87 physicians per 1000 inhabitants, demonstrating an uneven distribution of medical professionals. This distribution has led the government to invest in programs that facilitate the creation of medical schools (5). This has contributed to a change in the profile of physicians, leading the population of physicians to become much younger, with a higher proportion of females, despite the male majority in the Brazilian population (54.4% male vs. 45.6% female) (6). The aim of this paper was to analyze the profile and distribution of graduates from FMUSP.
were 21 to 75 years old. Duplicated or incomplete registry entries were excluded from the present study.
In our analysis, we divided all graduates in 53 medical specialties into the following three main areas: A review of historical documents, loaned by the Carlos da Silva Lacaz Historical Museum at FMUSP, allowed the collection of the data needed for the analysis of the years included in this study.
As an exploratory analysis, we plotted two Kernel density maps using a qualitative geographic information system open source software (QGis) for MDs who were FMUSP graduates and who were born either inside or outside of São Paulo City. This technique allows us to better visualize the overlap and proximity of the current work locations of the MDs via a color scale and visual analysis. Both maps have the same bandwidth, and their categories have the same breakpoint values to allow a better visual comparison.
This study was part of the ''Brazilian Medical Demography: Profile, Distribution, Work and Specialization of Physicians'' Project, approved by the FMUSP Ethics in Research Committee (Resolution 797.424 on 09/03/2014).
The authors then analyzed the data obtained, identifying correlations between these data and data from other medical demography studies. All data were analyzed using appropriate statistical methods with IBM 24.0 SPSS s software. A p-value less than 0.05 was considered statistically significant.  das Clínicas (HC) was founded. Today, it is a referral center for complex cases from across Brazil.
There are currently 7,419 physicians who are FMUSP graduates and who are younger than 70 years, accounting for approximately 1.7% of all currently working physicians in Brazil (432,870 in total) in 2015. Since the foundation of FMUSP in 1912 until 1976, the number of graduating MDs has gradually increased each year. Today, 175 students receive a medical degree from FMUSP annually, a number that is approximately 6 times larger than that of the first class in 1918. The demographic data of the FMUSP graduates are presented in Table 1.
We can observe that 68.6% of the physicians who have graduated from FMUSP are men. This is significantly different from the general profile of Brazilian physicians, 57.5% of whom are women. However, the proportion of females has grown impressively grown since the founding of FMUSP; it barely rose above 15% in the first 6 decades, reaching 24.5% in the 7 th decade, 37.5% on the 8 th decade and stabilizing approximately 37% on the following decades.
Concerning the medical specialties chosen by FMUSP graduates, there is a higher percentage of specialists in all areas among FMUSP graduates than among physicians in Brazil as a whole, according to the 2015 Medical Demography database. In total, 1,537 graduates do not have a specialty registered or it was not possible to access it (20.7% of the study group). The specialties with the largest numbers of graduates are General Surgery with 826 physicians (10.4%), Pediatrics with 594 (7.5%), Internal Medicine with 565 (7.1%), Gynecology and Obstetrics with 461 (5.8%), Orthopedics and Traumatology with 451 (5.7%), Psychiatry with 378 (4.8%) and Radiology with 359 (4.5%). According to the Brazilian Medical Demography database, among the specialists, 25.9% are in internal medicine, 13.5% are in surgical areas and 14.2% are in both (internal medicine and surgery-based). Table 2 shows all the specialties in detail.
FMUSP graduates and all Brazilian physicians have similar profiles in terms of the age group distribution of graduates aged 35 years or more. However, it has proportionally fewer young physicians (younger than 35 years old) when compared to national physician population. Table 3 shows that most of the graduates of FMUSP were born in São Paulo State (83.2%), followed by those born in neighboring states, like Minas Gerais, Rio de Janeiro and Paraná, as seen in Figure 2. In total, 94.5% of the students were born in one of the Southeast States (São Paulo, Rio de Janeiro, Minas Gerais or Espírito Santo), and most of the students were born in São Paulo City, where FMUSP is located. Students who were not born in Brazil account for a very small portion of graduates (0.4%).
The maps in Figure 2 show the geographic distribution of FMUSP graduates across Brazil; the graduates are divided into two groups, namely, those who were born in São Paulo City and those who were born outside of São Paulo City. Another characteristic of FMUSP graduates is the tendency to stay in São Paulo City. While 55.6% were born outside the city, 75.2% of FMUSP graduates practice medicine in São Paulo, resulting in an even larger concentration of medical professionals in the area.

' DISCUSSION
Over the 105 years of its history, FMUSP has occupied an important position in the formation of the Brazilian medical system. Being a pioneer makes it a global model in several areas (7) and one of the main healthcare education centers and the most important research center in the Health Sciences in Brazil (8).
It is curious to note that in the last three decades, the percentage of women at FMUSP has remained approximately 37.5%. This does not reflect Brazilian reality; in recent years, there has been an increasing proportion of female physicians graduating compared to their male counterparts, a proportion that is similar to that found in several medical schools around the world (9). In Brazil, since 2011, female physicians account for the majority of registered physicians (10).
Another noteworthy finding is that among FMUSP graduates, 33.6% do not have any registered medical specialty. This could reflect mainly an inefficiency in updating the database because this information is not mandatory. Furthermore, the average of unregistered specialties is still lower than the national average (46.4%) (6). Therefore, FMUSP still produces more specialists than the average Brazilian medical school. We believe this is related to the fact that the associated teaching hospital is a tertiary center with a concentration of highly complex cases.
The HC is the teaching hospital throughout the 6 years of education for FMUSP students. The hospital includes specialized institutes that focus on highly complex cases. The effect of a highly specialized center on medical training is still unknown. Sierles and Taylos have demonstrated a correlation between medical education and professional choices (11). Career choices directly affect the available medical workforce (12); therefore, it has the potential to affect health policy planning. There are substantial differences between the most common specialties in several countries, with various conditions linked to historical events in each country studied (13,14). The diversity of career choices can also be linked to all the medical specialties offered by the Hospital das Clínicas (HC) / FMUSP complex, the Medical Residency programs of which are attended by a large part of the institution's alumni.
Moreover, we observed a higher percentage of FMUSP graduates who were specialists compared with the general population of physicians in Brazil. Another interesting finding was the slightly higher prevalence of surgical specialties as the chosen career among FMUSP graduates compared to the national average [16.8% (95% CI 15.5%-17.6) versus 13.5%]. We believe that is related to the international recognition of and pioneering work performed by our institution's surgical groups (7).
It is notable, however, that a low percentage of our MDs go on to work in areas such as Family Medicine, Pediatrics and Obstetrics and Gynecology, which are essential to primary care and have direct impacts on public policy. We believe that these choices are related to the tertiary hospital in which the students practice and that this model is essential for wellbeing of the nation. Although FMUSP does not generate as many primary care physicians, it educates highly specialized individuals who are also important for the development of health care in Brazil. However, few studies have compared the level of the teaching hospital with the choices of specialties made by graduates.
In addition, the Kernel map shows one more interesting feature of FMUSP graduates; the students who come from other cities outside of São Paulo City tend to stay in São Paulo more often than do those who were born in the city. This phenomenon is shown in Table 4 and could be related to factors such as the greater size of the population (meaning that there would be a larger pool of patients for their chosen specialty), more modern technological resources, a known network, a larger number of hospitals and activity fields, as well as the possibility of maintaining a bond with the university (15,16). This disparity in the distribution of graduates agrees with the high percentage of physicians in São Paulo City, which has 23.7% of all physicians in the Southeast Region and 12.7% of all physicians in Brazil.  In 2013, the ''Mais Médicos'' law was promulgated in Brazil (law 12.871 on October 22, 2013), which stimulates the creation of new medical schools to provide more physicians for the Brazilian population. The law was highly criticized, with many suggesting that the focus should be on a better distribution of the existing physicians rather than on the training of additional physicians. The attachment of our students to the university's city, as previously observed by other authors, supports the critics of this law, as most of the new medical schools were created in the São Paulo region, whereas regions with fewer physicians per inhabitant such as Maranhão e Pará gained no new medical schools (17,18). It is our belief, therefore, that the law only contributes to a less equal distribution of Brazilian physicians.

' CONCLUSIONS
We believe that the characteristics of FMUSP may guide decisions related to public health and educational policies. The analysis of the century-long experience of FMUSP and its graduates allow us to make predictions about the outcomes of actions directed at improving public health.
As FMUSP has recently adopted affirmative action and racial quotas, we believe that our student profile will undergo even greater changes in the future. However, we believe that FMUSP remains an interesting model for the impact of a highly specialized center on the education and choices of medical students.

Limitations
Since this study is based on secondary data from different databases that are not always updated, it is expected that some data may be missing. Nevertheless, it was possible to determine a profile of the professionals who graduated from one of the largest medical education centers in Latin America, including their specialization. The database used in this study is, to the best of our knowledge, the best register of medical professionals in our country. In the future, these data could help establish health policy to foster medical education and to foment discussions on this topic.