Abstract

The 2014 National Curriculum Guidelines (DCN) for the medicine course provide for an education that focuses on primary care. The School of Medicine of Universidade Federal de Goiás, adapting itself to the new DCN, has developed a new Pedagogical Course Project (PCP). The objective of this study was to examine, through documentary analysis, the new PCP in the perspective of the 2014 DCN, based on the document “Guidelines for Primary Care Teaching in Undergraduate Medicine Courses”. Although the PCP covers most of the aspects related to primary care teaching, there is no reference to the teaching of the person-centered clinical method, popular health education, respect for patient autonomy, and shared decision-making. We hope, therefore, to subsidize changes in the current PCP and to stimulate other universities to approach these issues.

Keywords:
Primary care; Curriculum; Family and community medicine; Education

Introduction

Discussions about the medical curriculum gained momentum in the 20^th century, especially after the Flexner report was published in 1910. The report has influenced the reformulation of medical education in a large part of the world¹1 Marins JJ, Lampert JB, Araújo JG, organizadores. Educação médica em transformação: instrumentos para a construção de novas realidades. São Paulo: Hucitec; 2004.. This model was the basis for the organization of curricula, creating disciplines and showing the need of preventive and collective knowledge²2 Almeida Filho N. Reconhecer Flexner: inquérito sobre produção de mitos na educação médica no Brasil contemporâneo. Cad Saude Publica. 2010; 26(12):2234-49.. Flexner recognized that medical education must be configured in response to scientific changes and social and economic circumstances. Flexibility and freedom to change the curriculum, adapting to local social demands, were also part of his message³3 Cooke M, Irby DM, Sullivan W, Ludmerer KM. American medical education 100 years after the Flexner report. N Engl J Med. 2006; 355(13):1339-44..

Medical education and the graduates’ profile in Brazil up to 2000 were targeted predominantly at a hospital-centric and curative model⁴4 Streit DS, Neto FB, Lampert JB, Lemos JMC, Batista NA. Educação médica: dez anos de diretrizes curriculares nacionais. Rio de Janeiro: ABEM; 2012.. In response to this, the Ministry of Health, the Ministry of Education and some medical entities joined efforts to discuss the reformulation of medical education. These debates led to the creation of documents like the National Curricular Guidelines (DCN)⁵5 Ministério da Educação (BR). Conselho Nacional de Educação. Resolução CNE/CES 4/2001. Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina. Diário Oficial da União. 9 Nov 2001; sec. 1, p. 38. in 2001. Since then, efforts have been made to change the perspective of medicine courses, so that they focus on the population’s needs and on education in primary care⁶6 Bollela VR, Germani ACCG, Campos HH, Amaral E. Síntese final e as perspectivas para o futuro da educação baseada na comunidade no contexto Brasileiro. In: Bollela VR, Germani ACC, Campos HH, Amaral E, organizadores. Educação baseada na comunidade para as profissões da saúde: aprendendo com a experiência brasileira. Ribeirão Preto: FUNPEC-Editora; 2014. p. 293-7.. However, the low status of teaching activities outside universities or hospitals and the faculty’s insufficient knowledge of primary care activities represented challenges to a significant curricular change⁶6 Bollela VR, Germani ACCG, Campos HH, Amaral E. Síntese final e as perspectivas para o futuro da educação baseada na comunidade no contexto Brasileiro. In: Bollela VR, Germani ACC, Campos HH, Amaral E, organizadores. Educação baseada na comunidade para as profissões da saúde: aprendendo com a experiência brasileira. Ribeirão Preto: FUNPEC-Editora; 2014. p. 293-7..

In this context, the 2001 DCN for the medicine course⁴4 Streit DS, Neto FB, Lampert JB, Lemos JMC, Batista NA. Educação médica: dez anos de diretrizes curriculares nacionais. Rio de Janeiro: ABEM; 2012. represented an important step towards establishing a graduate profile more adequate to the population’s needs. In 2014, after discussions about the ‘More Doctors Law’⁷7 Presidência da República (BR). Lei 12.871, de 22 de Outubro de 2013. Institui o Programa Mais Médicos, altera as Leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013., new DCN for the medicine course were released⁸8 Ministério da Educação (BR). Conselho Nacional de Educação. Resolução CNE/CES 3/2014. Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina. Diário Oficial da União. 23 Jun 2014; sec. 1, p. 8-11.. Among the changes, the document highlighted the need of a generalist education, with emphasis on primary care and urgent/emergency services. It also recommended that the course’s fundamental contents should be related to the entire health-disease process of the citizen, family and community⁸8 Ministério da Educação (BR). Conselho Nacional de Educação. Resolução CNE/CES 3/2014. Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina. Diário Oficial da União. 23 Jun 2014; sec. 1, p. 8-11..

Primary care is the preferential entrance door to the health system and countries with a stronger inclination towards this level of care have better health indicators⁹9 Organização Mundial da Saúde. Atenção primária em saúde: agora mais do que nunca. Relatório Mundial da Saúde. Brasília: OPAS/Ministério da Saúde; 2010.^,1010 Organización Panamericana de la Salud. La renovación de atención primaria de salud em las Américas. Documento de posición de la Organización Panamericana de la Salud. Washington: OPAS; 2007.. However, for its full functioning, it is necessary to have professionals who are highly effective, know how to assist people over time, have knowledge of different conditions, and are able to coordinate the care received in different levels¹¹11 Starfield B. Is primary care essential? Lancet. 1994; 344(8):1129-33..

In this context, we analyzed the School of Medicine of Universidade Federal de Goiás (FM_UFG). It initiated its activities in 1960 and more than 5,000 doctors have already graduated from it. The majority of them practice their activities in the region, in different areas, including those of public and private management¹²12 Universidade Federal de Goiás. Projeto pedagógico do curso de medicina. Goiânia: UFG; 2014.. The institution has strived to adequate its teaching to the population and, as early as in the 1970s, it implemented a rural internship for the teaching of community medicine. In 2002, FM_UFG performed a curricular reform to comply with the 2001 DCN and, in the same year, it adhered to the Incentive Program to Curricular Changes in Medical Schools (Promed). In addition, in 2005, it adhered to the National Program of Reorientation of Professional Health Education (Pró-Saúde I and II), and in 2008, to the Education through Work Program for the Health Area (PET-Saúde). By adhering to these projects, the institution started to focus on health teaching activities in the community¹³13 Naghettini AV, Pereira ERS, Moraes VA. Educação baseada em comunidade: a experiência da Universidade Federal de Goiás. In: Bollela VR, Germani ACC, Campos HH, Amaral E, organizadores. Educação baseada na comunidade para as profissões da saúde: aprendendo com a experiência brasileira. Ribeirão Preto: FUNPEC; 2014. p. 125-36..

In 2014, aiming to comply with the new DCN for the medicine course, it published its new Pedagogical Course Project (PCP), which is still in the implementation and assessment stage. The PCP determines the guiding principles and the expectations for medical education in the institution¹²12 Universidade Federal de Goiás. Projeto pedagógico do curso de medicina. Goiânia: UFG; 2014..

Considering the need to review and adjust the curricula of all the Brazilian medical schools based on the 2014 DCN, this study aimed to analyze the PCP of the medicine course of FM_UFG in light of the determinations provided by the 2014 DCN and by the document “Guidelines for Primary Care Teaching in Undergraduate Medicine Courses”¹⁴14 Demarzo MM, Almeida RC, Marins JJ, Trindade TG, Anderson MI, Stein AT, et al. Diretrizes para o ensino na Atenção Primária à Saúde na graduação em Medicina. Rev Bras Med Fam Comunidade. 2011; 6(19):145-50..

Methods

This is a case study involving a qualitative approach, with data produced by means of a documentary analysis. According to Bardin¹⁵15 Bardin L. Análise de conteúdo. Reto LA, Pinheiro A, Tradutor. São Paulo: Edições 70; 2011., 2011, documentary analysis is an operation or set of operations that aim to represent the content of a document in a way that is different from the original, to facilitate, in a subsequent period, its consultation and reference.

As illustrated in Figure 1, three documents were analyzed and two were compared: The “Pedagogical project of the medicine course of FM_UFG”, published at the end of 2014, was compared to the “Curricular guidelines for the medicine course”, published in 2014.

The document “Guidelines for Primary Care Teaching in Undergraduate Medicine Courses”¹³13 Naghettini AV, Pereira ERS, Moraes VA. Educação baseada em comunidade: a experiência da Universidade Federal de Goiás. In: Bollela VR, Germani ACC, Campos HH, Amaral E, organizadores. Educação baseada na comunidade para as profissões da saúde: aprendendo com a experiência brasileira. Ribeirão Preto: FUNPEC; 2014. p. 125-36. was also analyzed to subsidize and establish the specifications of primary care teaching in undergraduate courses. This document was chosen because it is considered a reference in the area. It was jointly constructed by the Brazilian Association of Medical Education (ABEM) and by the Brazilian Society of Family and Community Medicine (SBMFC), with the collective participation of different Brazilian specialists in the areas of medical education and primary care. It was developed with the aim of supporting medical schools in the structuring of pedagogical projects within the context of primary care.

Initially, the researchers performed the exploratory reading of the “Guidelines for Primary Care Teaching in Undergraduate Medicine Courses” and extracted themes related to “what to teach” in this level of care. After this stage, the researchers selected twelve themes that had correspondents in the 2014 DCN:

Then, the researchers performed an initial exploratory reading of the PCP, to have contact and be familiarized with the text¹²12 Universidade Federal de Goiás. Projeto pedagógico do curso de medicina. Goiânia: UFG; 2014.. This document provides the principles and strategies of learning assessment, course duration and curricular structure, including the curricular matrix, the list of modules and the learning contents, with their respective summaries and numbers of hours¹⁰10 Organización Panamericana de la Salud. La renovación de atención primaria de salud em las Américas. Documento de posición de la Organización Panamericana de la Salud. Washington: OPAS; 2007.. All these topics were evaluated in this research.

Finally, by means of the thematic content analysis¹⁵15 Bardin L. Análise de conteúdo. Reto LA, Pinheiro A, Tradutor. São Paulo: Edições 70; 2011., the researchers searched for the previously chosen themes in the PCP and, subsequently, described and correlated them. They are presented in tables in the Results section (Figure 1).

The study was submitted to the Research Ethics Committee of Hospital das Clínicas of UFG and was initiated after its approval - Opinion no. 1.523.208 in 2016, according to resolution no. 466 of December 12, 2012, of the National Health Council (CNS).

Results and discussion

The four themes that resulted from the documentary analysis are presented in tables, together with the description and comparison between the documents. Chart 1 compares the documents according to the graduate profile, Chart 2 deals with the healthcare area, Chart 3 refers to aspects of health management, and Chart 4 approaches health education.

The expected graduate profile

The professional’s profile described in the PCP, a generalist doctor aligned with the society’s needs, is in agreement with the DCN. Education in primary care and social responsibility are highlighted in both documents (Chart 1).

The education of a medicine student with a generalist profile, knowledge of different healthcare levels and with social responsibility is aligned with the principles of the Brazilian National Health System (SUS)¹⁶16 Ministério da Saúde (BR). Portaria nº 2.488, de 21 de Outubro de 2011. Política Nacional de Atenção Básica em Saúde (PNAB). Diário Oficial da União. 22 Out 2011; sec. 1, p. 48-52.. Although the 2001 DCN for the medicine course⁵5 Ministério da Educação (BR). Conselho Nacional de Educação. Resolução CNE/CES 4/2001. Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina. Diário Oficial da União. 9 Nov 2001; sec. 1, p. 38. already contained these orientations, the medical schools have advanced slowly as far as this theme is concerned. Medical teaching in Brazil has had difficulties in transforming traditions and spaces of action⁴4 Streit DS, Neto FB, Lampert JB, Lemos JMC, Batista NA. Educação médica: dez anos de diretrizes curriculares nacionais. Rio de Janeiro: ABEM; 2012.. The publication of the ‘More Doctors Law’ in 2013⁷7 Presidência da República (BR). Lei 12.871, de 22 de Outubro de 2013. Institui o Programa Mais Médicos, altera as Leis nº 8.745, de 9 de Dezembro de 1993, e nº 6.932, de 7 de Julho de 1981, e dá outras providências. Diário Oficial da União. 23 Out 2013. instituted that medicine courses must comply with the DCN. Due to this, greater transformations are expected in the Brazilian medical education and in the university analyzed here.

To corroborate these orientations, and searching for experiences and standpoints from other countries, it is important to mention that the World Health Organization recommends that approximately eighty percent of the health demands are met in primary care¹⁷17 World Health Organization. The Ottawa Charter for health promotion. Geneva: WHO; 1986.. Furthermore, in White’s classic study “The ecology of medical care”, 1961¹⁸18 White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med. 1961; 265:885-92., replicated and confirmed in 2001 by Green¹⁹19 Green LA, Fryer GE Jr, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001; 344(26):2021-5., it was found that less than five percent of the people who look for medical assistance need hospital care. These data strengthen the need of an education that focuses on outpatient services, especially in primary care.

Healthcare

Chart 2 presents themes related to the Healthcare area, like care centered on the person, family and community, health promotion and prevention, utilization of scientific evidence, and competencies related to teamwork, development of popular education activities and shared decision-making.

The need to consider the person in their totality, including the family and community, is mentioned in both documents. However, the PCP does not mention the person-centered clinical method. This approach has many advantages in relation to the traditional biomedical model, centered on the doctor. Some of them are greater patient satisfaction, higher adherence to the treatment and better response to the therapy, greater doctor satisfaction, lower number of medical malpractice lawsuits, more efficient care, lower number of complementary exams and referrals to specialists, reducing costs to the health system and the patient²⁰20 Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev. 2012; 12:CD003267.^,2121 Lopes JM. Consulta e abordagem centrada na pessoa. In: Gusso G, Lopes J. Tratado de medicina de família e comunidade. São Paulo: Artmed; 2012. p. 112-23..

Prevention, health promotion and competence to work with popular education and with the team’s education are considered actions the student is expected to perform. The expression ‘health promotion’ was used for the first time in the 1970s by the Canadian health minister Mark Lalonde, in a document called The New Perspectives on the Health of Canadians.²²22 Oliveira DL. A 'nova' saúde pública e a promoção da saúde via educação: entre a tradição e a inovação. Rev Lat Am Enfermagem. 2005; 13(3):423-31. doi: 10.1590/S0104-11692005000300018.
https://doi.org/10.1590/S0104-1169200500... The influence of environmental factors, individual behaviors and ways of life on the occurrence of diseases and death were emphasized in this document. The Ottawa Charter, published by the World Health Organization in the first international conference on health promotion, strengthens this thesis and adds that individuals must be oriented to have better control over their own health¹⁷17 World Health Organization. The Ottawa Charter for health promotion. Geneva: WHO; 1986.^,2222 Oliveira DL. A 'nova' saúde pública e a promoção da saúde via educação: entre a tradição e a inovação. Rev Lat Am Enfermagem. 2005; 13(3):423-31. doi: 10.1590/S0104-11692005000300018.
https://doi.org/10.1590/S0104-1169200500... .

Although the PCP approaches the concept of permanent education and involves the population in this sense, there is no clear and specific mention to learning about Popular Health Education. Popular Health Education recognizes and faces health problems by interacting with the working classes and respecting their culture and knowledge. The current conception of Popular Health Education, influenced mainly by Paulo Freire’s publications, breaks with the previous hegemonic practices of health education. These used to be predominantly instituted in a unilateral way by health professionals. Their nature was essentially biomedical and not dialogic²³23 Gomes LB, Merhy EE. Compreendendo a educação popular em saúde: um estudo na literatura brasileira. Cad Saude Publica. 2011; 27(1):7-18.. Therefore, teaching these concepts in the medicine course has become fundamentally relevant²⁴24 Simon E, Jezine E, Vasconcelos EM, Ribeiro KS. Metodologias ativas de ensino-aprendizagem e educação popular: encontros e desencontros no contexto da formação dos profissionais de saúde. Interface (Botucatu). 2014;18 Suppl 2:1355-64. doi: 10.1590/1807-57622013.0477.
https://doi.org/10.1590/1807-57622013.04... .

The DCN mention the need to stimulate patients’ self-care, to respect their autonomy, and to encourage the professionals’ capacity for making shared decisions. However, it is important to highlight the absence, in the PCP, of any term related to respect for autonomy or shared decision. As shown below, many publications strengthen the DCN’s orientation about these matters. The 2009 code of medical ethics²⁵25 Conselho Federal de Medicina - CFM. Código de ética médica; Resolução CFM Nº 1931/2009. Diário Oficial da União. 24 Set 2009; sec. 1, p. 90. establishes, in article 21, that in the professional decision-making process, according to the doctor’s dictates of conscience and the legal dispositions, the doctor will accept their patients’ choices related to diagnostic and therapeutic procedures, provided that they are adequate to the case and scientifically recognized.

The predominance of chronic degenerative diseases instead of acute diseases will require the reincorporation of the art of medicine, according to Sullivan, 2003²⁶26 Sullivan M. The new subjective medicine: taking the patient´s point of view on health care and health. Soc Sci Med. 2003; 56(7):1595-604.. The exclusive objective of curing and avoiding death is replaced by the objective of providing care for people, considering their perspective. Respect for patient autonomy and the importance given to their point-of-view in relation to health and care is a fundamental part of the doctor’s action. The patient-subject is being reintroduced in medicine²⁶26 Sullivan M. The new subjective medicine: taking the patient´s point of view on health care and health. Soc Sci Med. 2003; 56(7):1595-604.^,2727 Ribeiro MM, Amaral CF. Medicina centrada no paciente e ensino médico: a importância do cuidado com a pessoa e o poder médico. Rev Bras Educ Med. 2008; 32(1):90-7..

Evidence-based decision-making considering the prevalence and incidence of different health problems is mentioned in both documents. This form of action ensures greater efficacy and effectiveness to treatments, attention to quaternary prevention, rational use of resources and medicines, and reduction in cases of iatrogenesis²⁸28 Manser R, Walters EH. What is evidence-based medicine and the role of review: the revolution coming your way. Monaldi Arch Chest Dis. 2001; 56(1):33-8.^,2929 Oannidis JP. Evidence-based medicine has been hijacked: a report to David Sackett. J Clin Epidemiol. 2016; 73:82-6..

Health Management

This topic deals with matters like teamwork, leadership in multidisciplinary work, and knowledge of management actions. All these competencies are recommended by the DCN and PCP (Chart 3).

With the population’s aging and the increase in chronic conditions, the complexity of care has been significantly amplified³⁰30 Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010; 376(9756):1923-58. doi: 10.1016/S0140-6736(10)61854-5.
https://doi.org/10.1016/S0140-6736(10)61...

31 Ornstein SM, Nietert PJ, Jenkins RG, Litvin CB. The prevalence of chronic diseases and multimorbidity in primary care practice: a PPRNet report. J Am Board Fam Med. 2013; 26(5):518-24.^-3232 Barreto MS, Carreira L, Marcon SS. Envelhecimento populacional e doenças crônicas: reflexões sobre os desafios para o Sistema de Saúde Pública. Rev Kairós Gerontol. 2015; 18(1):325-39.. Therefore, the education of professionals to face this new epidemiological profile has become fundamental. Teamwork and leadership in a collaborative, non-hierachic and coordinated way are indispensable competencies in this process³⁰30 Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010; 376(9756):1923-58. doi: 10.1016/S0140-6736(10)61854-5.
https://doi.org/10.1016/S0140-6736(10)61... ^,3333 Furtado JF. Equipes de referência: arranjo institucional para potencializar a colaboração entre disciplinas e profissões. Interface (Botucatu). 2007; 11(22):239-55.^,3434 Matuda CG. Colaboração interprofissional na Estratégia de Saúde da Família: implicações para a produção do cuidado e a gestão do trabalho. Cienc Saude Colet. 2015; 20(8):2511-21..

Despite its subjective character, leadership is a competency that can be taught. It involves good communication, knowing how to work in teams, strategic planning and decision-making. In addition, the student is expected to identify needs, set goals and work in teams, trying to involve other professionals in order to share the provision of care with them³⁵35 Provenzano BC, Ferreira DAV, Machado APG, Aranha RN. Liderança na educação médica. Rev HUPE. 2014; 13(4):26-31..

The development and knowledge of management actions - another desired competency - involves the organization of health systems and public healthcare. Educating the student to be familiarized with and manage the macrostructure and also the public policies and services is a measure that will bring better qualified professionals and managers, committed to the improvement in the healthcare network devices³⁶36 Gontijo ED, Alvim C, Megale L, Melo JRC, Lima MECC. Matriz de competências essenciais para a formação e avaliação de desempenho de estudantes de medicina. Rev Bras Educ Med. 2013; 37(4):526-39..

An action that aims at the provision of comprehensive care is a fundamental stage of medical assistance in primary care. The clinical approach centered on the integral, complex person guarantees that the individual is seen in their totality. It is an strategy to fulfil an assistance targeted at the population’s real needs³⁷37 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Unesco, Ministério da Saúde; 2002..

Health Education

In the section of the DCN referring to the area of Health Education, an issue with an interface in primary care is highlighted: interdisciplinarity. Interdisciplinarity is mentioned in the PCP (Chart 4).

Interdisciplinarity, which means the interaction among different theories and knowledge from different areas in teaching-learning processes³³33 Furtado JF. Equipes de referência: arranjo institucional para potencializar a colaboração entre disciplinas e profissões. Interface (Botucatu). 2007; 11(22):239-55., is essential for the education of a professional who works in an integrated, interprofessional and efficient manner³⁴34 Matuda CG. Colaboração interprofissional na Estratégia de Saúde da Família: implicações para a produção do cuidado e a gestão do trabalho. Cienc Saude Colet. 2015; 20(8):2511-21..

According to Frenk et al.³⁰30 Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010; 376(9756):1923-58. doi: 10.1016/S0140-6736(10)61854-5.
https://doi.org/10.1016/S0140-6736(10)61... , interdisciplinarity and interprofessionality are pillars of the last substantial generation of reforms in medical education that deal with the acquisition of competencies for the education of a professional aligned with the population’s needs.

Final remarks

The new curricular pedagogical project was constructed within a context of transformations in medical education and in the care model (after the ‘More Doctors Law’) and complied with the 2014 DCN in the majority of points related to primary care teaching in undergraduate courses.

Both documents determine the education of a generalist professional who meets the population’s health needs and has extensive knowledge of primary care. The documents also describe the need to educate graduates to have a comprehensive approach, skills to work in teams, and knowledge of management processes.

However, it is important to mention the absence, in the PCP, of fundamental themes to medical practice and to the doctor-patient relationship. There is no reference to the teaching of the person-centered clinical method, popular health education, respect for patient autonomy, and shared decision-making.

Thus, we hope that managers of the analyzed course and of other institutions with similar contexts, in a process of assessment and continuous reformulation of the curriculum, can include these recommendations, set forth in the 2014 DCN and fundamental to the practice of a humanized, effective medicine, centered on the people’s and population’s needs.

References

Publication Dates

History