Only a doctor can evaluate a doctor's decisions
Em São Paulo, médicos brasileiros reuniram-se para reafirmar um princípio que a burocracia frequentemente obscurece: a decisão clínica pertence à esfera técnica e ética, não à contábil. O debate sobre auditoria médica revelou uma tensão antiga entre o cuidado ao paciente e os interesses econômicos dos operadores de saúde. O que estava em jogo não era apenas um procedimento administrativo, mas a própria definição de medicina — uma prática que, quando reduzida a planilhas, perde sua razão de ser.
- Pacientes estão sendo submetidos a procedimentos por profissionais que não são médicos, muitas vezes sem saber a diferença — uma falha sistêmica que o Conselho Federal de Medicina decidiu tornar visível por meio de uma plataforma de rastreamento.
- A auditoria médica, concebida para garantir qualidade, tem sido desvirtuada em ferramenta de contenção de custos, colocando em risco a autonomia clínica dos médicos e, por consequência, a segurança dos pacientes.
- Especialistas defendem que apenas um médico pode avaliar as decisões de outro médico — um princípio que não admite exceções e que precisa ser respaldado por resoluções do Conselho Federal de Medicina.
- O caminho apontado exige alinhamento entre diretores técnicos, auditores, médicos assistentes e operadoras de saúde, todos operando a partir de critérios técnicos e evidências científicas, não de metas orçamentárias.
- O auditor ideal não é o guardião que nega, mas o validador que fundamenta cada decisão em raciocínio clínico transparente — eliminando desperdício sem eliminar benefício.
Numa manhã de junho em São Paulo, a Associação Médica Brasileira abriu o quarto Congresso de Medicina Geral com um debate que parece técnico, mas é profundamente humano: quem decide o que os médicos fazem, e com base em quê. O tema era a auditoria médica — e o que ela revela sobre os limites entre cuidado e custo.
O Dr. José Eduardo Lutaif Dolci, diretor científico da AMB, foi direto: a auditoria não é periférica à prática médica, é central. Médicos que não compreendem o sistema correm o risco de vê-lo moldado sem sua participação.
A Dra. Rosylane Rocha, do Conselho Federal de Medicina, apresentou uma plataforma criada para registrar casos em que procedimentos médicos foram realizados por profissionais não habilitados. O problema é duplo: pacientes não sabem distinguir quem está qualificado para agir, e as consequências podem ser graves. A plataforma coleta dados sobre complicações, denúncias e profissionais envolvidos, com o objetivo de produzir relatórios públicos e recomendações às autoridades. Rocha também reforçou que cada operadora de saúde precisa de um diretor técnico médico responsável perante o conselho regional — e que somente um médico pode avaliar as decisões de outro médico.
O Dr. Carlos Magno Dalapicola foi ainda mais direto ao responder o que um auditor médico deve fazer. Sua resposta foi uma crítica a uma prática comum: o auditor não deve ser agente de contenção de custos, mas garantidor de qualidade, adequação e segurança. Pode questionar diagnósticos, exames ou procedimentos — mas apenas com fundamentação científica objetiva. O equilíbrio exigido é delicado: eliminar desperdício sem suprimir benefício, adotar inovações apenas quando respaldadas por evidências.
O que emergiu do congresso foi uma inversão de perspectiva: em vez de auditores como barreiras que negam, uma visão em que eles validam e explicam, com linguagem que resiste ao escrutínio técnico. A auditoria orientada por metas orçamentárias não foi apresentada como eficiente — foi apresentada como perigosa. Uma lembrança de que medicina é uma prática técnica que não se reduz a contabilidade.
On a June morning in São Paulo, the Brazilian Medical Association gathered its members for a conversation that cuts to the heart of modern healthcare: who decides what doctors do, and on what grounds. The fourth General Medicine Congress opened with a panel on medical auditing—a topic that sounds bureaucratic until you realize it determines whether patients get the care they need or whether cost concerns override clinical judgment.
Dr. José Eduardo Lutaif Dolci, the Association's scientific director and a professor of otolaryngology at Santa Casa de São Paulo, framed the stakes plainly. Medical auditing, he told the room, was not peripheral to practice. It was central to it. Doctors needed to understand the system and engage with it actively, or risk having it shaped without their voice.
The first speaker, Dr. Rosylane Nascimento das Mercês Rocha—a occupational medicine physician with a doctorate in bioethics and a seat on Brazil's Federal Medical Council—presented a platform the Council had built to track unsafe practices. The problem it addressed was straightforward: patients were having medical procedures performed by people who were not doctors. Worse, patients often could not tell the difference. The public did not know what constituted a medical act, what required a physician's license, or why another professional could not simply do the work. The platform collected data on these cases—patient information, the procedure performed, complications, injuries, where it happened, formal complaints, and the professionals involved. The Council would analyze this data and publish reports to the public and authorities, with recommendations for action. It was a way of making visible what was happening in the shadows.
Rocha also addressed the role of technical directors at health plans, insurance companies, medical cooperatives, and self-managed providers. Every operator needed a physician responsible to the regional medical council. That director had to ensure quality of care, oversee audits, and maintain formal relationships with doctors and providers. The Federal Medical Council had issued a resolution on medical auditing with a clear purpose: protect patients and strengthen physicians' professional rights. Only a doctor could evaluate a doctor's decisions, she emphasized. That was not negotiable.
The third speaker, Dr. Carlos Magno Pretti Dalapicola, a federal councilor from Espírito Santo and occupational medicine specialist, addressed the question directly: what should a medical auditor actually do? His answer was a rebuke to a common practice. The auditor should not be a cost-containment agent. The auditor should be a guarantor of quality, appropriateness, and safety. Medical auditing must rest on technical criteria, scientific evidence, and patient safety—not economic interests. The auditor does not replace the treating physician. The auditor evaluates whether the clinical reasoning is sound, whether the approach aligns with established guidelines, whether the resources requested are justified. An auditor can question a diagnosis, an exam, a material, a procedure—but only with objective, clear, scientific reasoning. The work demands balance: eliminate waste without eliminating benefit, adopt innovation only when evidence supports it, protect resources without compromising clinical outcomes.
What emerged from the morning was a framework for auditing that inverts the usual power dynamic. Instead of auditors as gatekeepers who say no, they become validators who say yes—or explain why not, in language that stands up to scrutiny. The system depends on alignment: medical directors, auditors, treating physicians, and health operators all working from the same technical and ethical foundation. The alternative—auditing driven by budget targets rather than clinical standards—was presented not as efficient but as dangerous. It was a claim about what medicine actually is: a technical practice that cannot be reduced to accounting.
Notable Quotes
The auditor should be a guarantor of quality, appropriateness, and safety—not a cost-containment agent— Dr. Carlos Magno Pretti Dalapicola, federal councilor and occupational medicine specialist
The public does not know what constitutes a medical act, what requires a physician's license, or why another professional cannot simply do the work— Dr. Rosylane Nascimento das Mercês Rocha, occupational medicine physician and Federal Medical Council member
The Hearth Conversation Another angle on the story
Why does it matter whether an auditor is a doctor? Couldn't a trained administrator review the same records and ask the same questions?
Because evaluating whether a clinical decision was sound requires understanding medicine itself—not just the paperwork. A non-physician auditor might see that a test was ordered and ask if it was necessary. A physician auditor understands the clinical context that made it necessary. One catches waste; the other understands care.
But doesn't that give doctors a way to avoid scrutiny? If only doctors can audit doctors, who checks them?
That's the real tension. The resolution tries to solve it by saying auditors must use scientific evidence and established guidelines, not personal preference. The auditor is not a peer protecting a peer. The auditor is bound to the same standards the treating physician should be following.
What about the platform the Council created to track unsafe practices by non-physicians? That seems like it's about something different—illegal practice, not auditing.
It is different, but connected. If patients can't tell who's qualified to do what, they end up in the hands of people without training. The platform makes that visible. It's a way of saying: this is happening, here's the data, here's what needs to change.
And the technical directors at health plans—what's their actual power?
They're supposed to be the bridge. They answer to the medical council, not just to the company's finance department. In theory, they protect both the patient and the physician from pressure to cut corners. In practice, that depends on whether they have real autonomy.