ABSTRACT

The new National Curriculum Guidelines aim at restructuring and adapting medical curricula. The objective is to conduct a critical-reflective analysis of the restructure of a medical course’s curricular matrix. This action research was conducted at a Brazilian federal university. The material was analyzed using the discourse analysis method. Among the results, the proposal of a curriculum that values life and transfers the biomedical paradigm to incorporate other dimensions in healthcare is highlighted. The need to strengthen a curricular matrix based on social demands and preferably focused on primary care is indicated. The establishment of longitudinal and transversal relationships among the competency areas of the 2014 National Curricular Guidelines and the curricular components is proposed. The intention is to foster the understanding of determinants and relationships between diseases and the communities’ ways of living.

Keywords:
Medical education; Curriculum; Primary healthcare; Collective health; Comprehensive care

Introduction

The 21^st century exposed the health systems’ weakness in dealing with three main problems: parasitic-infectious diseases, chronic non-transmitted diseases and external causes. It also exposed the mismatch between medical education and the population’s main health needs¹1 Amoretti R. A educação médica diante das necessidades sociais em saúde. Rev Bras Educ Med. 2005; 29(2):136-46..

Part of this inconsistency between professional education and health needs is related to a historical process of curricula development that is often decontextualized, fragmented and focused on technique. At least three generations of important educational reforms can be highlighted under this context²2 Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010; 376(4):1923-58.. The first one was a paradigmatic change unleashed after the publication of the Flexner Report in the early 1920s. The report consolidates education in hospital environments as privileged scenarios of medical practice²2 Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010; 376(4):1923-58..

The second reform introduced pedagogical innovations, such as Problem-Based Learning (PBL), active methodologies and work in small groups in the education of health professionals. Medical schools were particularly encouraged to break with hierarchical structures and traditional teaching models in order to adopt student-centered teaching and learning methodologies³3 Cyrino E, Toralles-Pereira M. Trabalhando com estratégias de ensino-aprendizado por descoberta na área da saúde: a problematização e a aprendizagem baseada em problemas. Cad Saude Publica. 2004; 20(3):780-8..

The third generation of changes gains strength in educational systems based on the concept of social accountability. This term still lacks a proper translation into Brazilian Portuguese, since it is not restricted to its direct translation, which means “social responsibility.” It is related to a commitment with accountability, a relationship that begins by welcoming social and healthcare concerns of communities, regions or nations in order to guide teaching, research and service activities⁴4 Boelen C, Heck J. Defining and measuring the social accountability of medical schools [Internet]. Geneva: World Health Organization; 1995 [citado 12 Set 2017]. Disponível em: http://apps.who.int/iris/bitstream/10665/59441/1/WHO_HRH_95.7.pdf
http://apps.who.int/iris/bitstream/10665... . Therefore, it is characterized by the educational institutions’ need for engagement in order to improve the health systems’ performance, adapting essential professional competencies to specific contexts and scenarios¹1 Amoretti R. A educação médica diante das necessidades sociais em saúde. Rev Bras Educ Med. 2005; 29(2):136-46..

In Brazil, the Healthcare Reform can be considered the forefront of this new paradigm, since it contributed to the institutionalization of the education of human resources for health through the Federal Constitution. According to the Organic Health Law no. 8080/90, the ordinance of the education process of these professionals should be guided by the Brazilian National Health System (SUS) according to the population’s most prevailing health needs⁵5 Presidência da República (BR). Lei nº 8.080, de 19 de Setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União. 19 Set 1990..

Aligned to this aspect, conformation of Collective Health becomes important, based on criticisms to the biomedical education model. It is instituted as an expansion of a paradigm that incorporates a biopsychosocial perspective of individuals and extrapolates its pedagogical conception to beyond hospital walls, guiding experiences and educational views also towards communities⁶6 Nunes E. Saúde coletiva: uma história recente de um passado remoto. In: Campos GWS, Bonfim JRA, Minayo MCS, Akerman M, Drumond Júnior M, Carvalho YM, organizadores. Tratado de saúde coletiva. São Paulo: Hucitec; 2012. p. 17-37..

Over the last three decades, several significant actions were suggested in the form of documents and legislation in Brazil (Figure 1). These initiatives have been contributing to foster the debate on the education of health professionals⁷7 Ministério da Saúde (BR). Anais da 8a Conferência Nacional de Saúde. Brasília: Ministério da Saúde; 1986.

8 Ministério da Educação (BR). Conselho Nacional de Educação. Diretrizes curriculares nacionais dos cursos de graduação em enfermagem, medicinas e nutrição. Brasília: Ministério da Educação; 2001.

9 Presidência da República (BR). Lei nº 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.

10 Ministério da Saúde (BR). Secretaria de Gestão do Trabalho e da Educação na Saúde. Programa Mais Médicos - dois anos: mais saúde para os brasileiros. Brasília: Ministério da Saúde; 2015.

11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014.

12 Portaria Interministerial nº 2.101, de 3 de Novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde - para os cursos de graduação em Medicina, Enfermagem e Odontologia. Diário Oficial da União. 3 Nov 2005.

13 Severino AJ. Metodologia do trabalho científico. São Paulo: Cortez; 2007.^-1414 Ibiapina IMJM, Bandeira HMM. Pesquisa-ação crítica: origem e desenvolvimento do campo teórico-prático. In: Ibiapina IMJM, Bandeira HMM, Araújo FAM. Pesquisa colaborativa: multirreferenciais e práticas convergentes. Piauí: EDUFPI; 2016..

A great milestone to be highlighted is the publication of the National Curricular Guidelines of medical courses, in 2001⁸8 Ministério da Educação (BR). Conselho Nacional de Educação. Diretrizes curriculares nacionais dos cursos de graduação em enfermagem, medicinas e nutrição. Brasília: Ministério da Educação; 2001., which already indicated a concern towards a general, human, critical and reflective education. Additionally, they suggested the division of the curriculum’s competencies into six topics: healthcare, decision making, communication, leadership, administration and management, and permanent education⁸8 Ministério da Educação (BR). Conselho Nacional de Educação. Diretrizes curriculares nacionais dos cursos de graduação em enfermagem, medicinas e nutrição. Brasília: Ministério da Educação; 2001..

In 2013, the Brazilian government launched the More Doctors Program through Law 12871. The program sets guidelines to reorient undergraduate and postgraduate medical education. Among its objectives, the establishment of new parameters to medical education in the country is highlighted⁹9 Presidência da República (BR). Lei nº 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.^,1010 Ministério da Saúde (BR). Secretaria de Gestão do Trabalho e da Educação na Saúde. Programa Mais Médicos - dois anos: mais saúde para os brasileiros. Brasília: Ministério da Saúde; 2015..

In 2014, the new National Curricular Guidelines of undergraduate medical courses were published¹¹11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014.. Their scope includes the need to qualify future professionals to work in different care levels. Additionally, they reinforce the commitment with human dignity, comprehensive care and transversality of practice guided by social determination of the health-disease process¹¹11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014..

Unlike the 2001 National Curricular Guidelines, their 2014 version emphasizes Collective Health. They lay out key planned and conducted actions based on demographic, epidemiological, healthcare and environmental data, considering dimensions of risk and vulnerability of collectivities. They also divide competency areas into three thematic axes: healthcare, health management, and health education¹²12 Portaria Interministerial nº 2.101, de 3 de Novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde - para os cursos de graduação em Medicina, Enfermagem e Odontologia. Diário Oficial da União. 3 Nov 2005..

Undergraduate medical courses throughout Brazil have made efforts towards restructuring and readapting their curricula in order to meet the new National Curricular Guidelines. This manuscript’s starting point is based on the need to redesign the current curriculum of a medical school in the Brazilian northeastern region, aimed at adapting it to the new 2014 National Curricular Guidelines. After 17 years of its last change, the current curriculum of this school requires modifications. The reasons for this change are: predominance of scenarios of practice in hospitals, insufficient inclusion of theoretical and practical activities related to Collective Health in general and specifically primary healthcare, and low planning and execution of activities guided towards social determination of the health-disease process. In this context, the object is to conduct a critical and reflective analysis of the restructure process of the curricular matrix of a Brazilian northeastern federal public university’s medical course.

Methodology

The adopted investigation methodology was a participatory action research. It aims at understanding and intervening in the situation in order to change it. This investigation process is conducted through a continuous spiral of action and reflection¹³13 Severino AJ. Metodologia do trabalho científico. São Paulo: Cortez; 2007.. The phases of the action research can overlap. The initial plans can sometimes change according to the reflection processes the researchers and participants go through¹⁴14 Ibiapina IMJM, Bandeira HMM. Pesquisa-ação crítica: origem e desenvolvimento do campo teórico-prático. In: Ibiapina IMJM, Bandeira HMM, Araújo FAM. Pesquisa colaborativa: multirreferenciais e práticas convergentes. Piauí: EDUFPI; 2016..

In this study, the participatory action research was outlined in three moments: creation of a theoretical framework, practical action and permanent assessment/reflection. All moments of the design process of a new curricular matrix of the medical course focused on Collective Health in light of the 2014 National Curricular Guidelines were part of a spiral movement and were experienced in it, according to the participatory action research’s premises¹⁴14 Ibiapina IMJM, Bandeira HMM. Pesquisa-ação crítica: origem e desenvolvimento do campo teórico-prático. In: Ibiapina IMJM, Bandeira HMM, Araújo FAM. Pesquisa colaborativa: multirreferenciais e práticas convergentes. Piauí: EDUFPI; 2016..

The investigation scenario was the undergraduate medical course of Universidade Federal do Ceará, in the Brazilian city of Fortaleza. The university was a pioneer in medical education, being the first medical school of the state. The course was considered a reference to the organization of the curricular matrices of the other courses that followed it. Additionally, the university is the higher education institution that offers more seats in the state¹⁵15 Lampert JB, Costa NMC, Perim GL, Abdalla IG, Aguilar-da-Silva RH, Stella RCDR. Tendências de mudanças em um grupo de escolas médicas brasileiras. Rev Bras Educ Med. 2009; 33(1):19-34..

Administratively speaking, the School of Medicine is divided into eight departments, such as the Community Health Department, which is the analytical object of this article. This department is co-responsible for the pedagogical organization of the only two mandatory longitudinal curricular components that are present in all semesters of the course: Primary Healthcare and Personal Development. It is also responsible for coordinating the Community Health Residency, focused on primary care. The department is connected with the fields of Epidemiology; Social and Human Sciences; Health, Work and Environment; and Health Policy and Planning.

The research subjects were teachers and coordinators of longitudinal modules offered by the Community Health Department. Technical servants who contribute to undergraduate teaching, such as nurses, doctors and educators, were also part of the study.

The research was conducted from March 2015 to April 2016. During this period, four thematic seminars were held. Among them, three were determined according to preestablished competency areas of medical education: I - Healthcare; II - Health management; and III - Health education¹¹11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014.. They aimed at discussing the new guidelines in order to lead curricular changes that can go beyond a simple pragmatic exercise. The fourth seminar was held with the objective of presenting the systematization’s results to the Community Health Department’s board in order to collectively validate them. The number of participants varied in each seminar. However, at least one representative of each module was present in all meetings, accounting for at least seven participants in each moment. Seminars were facilitated by an educator with experience in redesigning undergraduate health course’s pedagogical projects.

The following guiding questions were used to conduct the seminars: “What to teach?”, “Why teaching?”, “What to teach for?” and “Whom to teach for?” Based on these questions, each participant was encouraged to individually question and write their ideas about their current pedagogical practice using the competency areas in their three thematic axes: healthcare, health management and health education. The new 2014 National Curricular Guidelines were used as an analytical reference model. The objective was to promote an ontological reflection about the nature of the teaching and learning process, knowledge production, culture and society¹⁶16 Silva TT. Documento de identidade: uma introdução às teorias do currículo. Belo Horizonte: Autêntica; 2011..

The results of each seminar were transcribed, systematized, categorized and presented in the subsequent seminar, generating new reflections, debates, discussions and production. Therefore, participation was fostered in three moments: individual, small groups and plenary. The thematic categories¹⁷17 Pinto MJ. Comunicação e discurso: introdução a análise de discurso. São Paulo: Hacker Editores; 1999. were organized in accordance with the 2014 National Curricular Guidelines following the areas presented in the resolution: healthcare, health management and health education¹¹11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014.. They were subsequently analyzed and discussed in light of the scientific literature.

Discourse analysis was used to analyze the qualitative material. This method aims at “critically describing, explaining and assessing the processes of production, circulation and consumption of senses”¹⁷17 Pinto MJ. Comunicação e discurso: introdução a análise de discurso. São Paulo: Hacker Editores; 1999. (p. 7). Therefore, in discourse analysis, not only what is said or evidenced by the text matters. It also aims at understanding how a symbolic object produces senses and how it is invested in significance to and by subjects, since every speech is a form of action¹⁸18 Orlandi EP. Análise de discurso: princípios e procedimentos. Campinas: Pontes Editora; 2000..

In order to do so, discourses essentially need to be understood and interpreted as determinant social practices and social practices determined by the sociohistorical context. After all, discourse analysts are not placed out of history, symbolism or ideology. They are positioned as to be able to contemplate and act upon the sense production process and their conditions¹⁸18 Orlandi EP. Análise de discurso: princípios e procedimentos. Campinas: Pontes Editora; 2000.. This is the only way they are capable of interpreting and reinterpreting their textual corpus¹⁷17 Pinto MJ. Comunicação e discurso: introdução a análise de discurso. São Paulo: Hacker Editores; 1999.. It was also agreed upon among the participants that speeches from seminars would not be dealt with in an individual way. On the contrary, they would be analyzed as a collective product of each meeting, being identified by the letter “S” followed by the seminar number.

This research was approved by the Research Ethics Committee of Universidade Federal do Ceará under opinion number 04350712.4 0000.5054/2013.

Results and discussion

Medical education’s competency areas and their interface with Collective Health

In order to begin the critical and reflective analysis of the 2014 National Curricular Guidelines, the propositions of each competency area and their key actions were questioned. This decision was made because these sections contain possibilities of transforming the guidelines into relevant, adequate and timely effective practices in medical education¹¹11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014..

Healthcare

Regarding the first competency area, healthcare is structured into two subareas: care for individual health needs and care for collective health needs. Even under the scope of care for individual needs, the group of teachers identified relevant contributions to Collective Health in medical education. Among them, the resignificance of the biomedical paradigm is highlighted, moving towards a shared management of clinic with patients, repositioning them as protagonists of their own care process:

However, overcoming the biomedical paradigm to focus on a person-centered transition does not seem to be a consensus in professional practice and scientific literature. The doctor-centered paradigm is still oftentimes considered an element of power. Authors as Bursztyn¹⁹19 Bursztyn I. Diretrizes curriculares nacionais de 2014: um novo lugar para a Saúde Coletiva? Cad ABEM. 2015; 2:6-19. highlight that care for individual needs is a prominent domain in doctors: "Clinic, called Individual Healthcare here, is an undeniable space of leadership to doctors. Collective Health, called Care for Collective Health Needs here, is a domain in which doctors cooperate with other professionals"¹⁹19 Bursztyn I. Diretrizes curriculares nacionais de 2014: um novo lugar para a Saúde Coletiva? Cad ABEM. 2015; 2:6-19. (p. 15).

Under this scope, strengthening a care education generally focused on caring for diseases in their bodily manifestation is prioritized. It is also worth highlighting that fostering an anachronistic thought that suggests a hierarchy of medical professionals towards other health categories also seems counterproductive, particularly when the complexity and multicausality of problems that span the health-disease binomial are taken into consideration.

However, delimiting clinic as an undeniable space of leadership of doctors goes against the guidance contained in the new National Curricular Guidelines’ framework. According to the document, the following should prevail in medical education:

Another confluence point identified between the new 2014 National Curricular Guidelines and Collective Health is the development of shared therapeutic plans. These plans provide for the discussion of the treatment with the person under care, considering the use of popular health practices¹¹11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014.. In this perspective, a theoretical alignment with the contributions of Individual Therapeutic Projects (PTS) was identified²⁰20 Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Clínica ampliada, equipe de referência e projeto terapêutico singular. 2a ed. Brasília: Ministério da Saúde; 2008.^,2121 Campos G. Clínica e saúde coletiva compartilhadas: teoria PAIDEIA e reformulação ampliada do trabalho em saúde. In: Campos GWS, Bonfim JRA, Minayo MCS, Akerman M, Drumond Júnior M, Carvalho YM. Tratado de Saúde Coletiva. São Paulo: Hucitec; 2012. p. 39-78..

PTS is a series of proposals and articulated therapeutic conducts for an individual or a group resulting from the collective discussion of an interdisciplinary team²¹21 Campos G. Clínica e saúde coletiva compartilhadas: teoria PAIDEIA e reformulação ampliada do trabalho em saúde. In: Campos GWS, Bonfim JRA, Minayo MCS, Akerman M, Drumond Júnior M, Carvalho YM. Tratado de Saúde Coletiva. São Paulo: Hucitec; 2012. p. 39-78.. It is an important tool, since it creates opportunities for interdisciplinary dialogs among health teams and suggests actions that go beyond fighting diseases:

The proposal of a group of teachers and technicians to redesign the curricular matrix of the undergraduate medical course of Universidade Federal do Ceará was towards strengthening the expanded clinic. The expanded clinic is considered an important strategy to overcome the fragmented point of view. This essentially curative and hospital-centered view is still the basis of education in several medical schools²²22 Feuerwerker L. Além do discurso de mudança na educação médica: processos e resultados. São Paulo: Hucitec; 2002..

In this context, confluence among clinic and Collective Health is an opportunity. Despite acknowledging that both have their own spaces of domain or specific scientific fields²³23 Bourdieu P. O poder simbólico. 14a ed. Rio de Janeiro: Bertrand Brasil; 2010., the objects of their praxis converge towards the responsibility for healthcare.

Based on this focus, clinic and Collective Health are no longer dichotomous knowledge fields. On the other hand, the combination of these paradigms excessively contributes to a general medical education with expanded view. This education acknowledges the complexity that permeates the health-disease process in its different biological, subjective, socioeconomic, healthcare and cultural dimensions.

Before representing dichotomous and disconnected spaces that are unattractive to students¹⁹19 Bursztyn I. Diretrizes curriculares nacionais de 2014: um novo lugar para a Saúde Coletiva? Cad ABEM. 2015; 2:6-19., confluence between clinic and Collective Health in the curricular matrix of medical courses contributes to a human, ethical, critical and reflective education. Therefore, it can be aligned to the population and community’s health needs and their epidemiological reality. Additionally, it strengthens the development of health promotion and disease prevention actions, with an analytical focus on therapeutic practice, social determination and health-disease process¹¹11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014..

Health education and management

In the seminars, confluence between the National Curricular Guidelines’ guidance and Collective Health, related to health education and management, was also identified. In this context, reflection on the potentialities of scenarios of practice to a systematic dialog between medical students and communities during their education was also prioritized. Therefore, the creation of fruitful ambience for the development of continuous reflection/education processes regarding health practices was facilitated. These health practices are also limited and referenced by users of health services²⁴24 Ferreira R, Silva R, Aguer C. Formação do profissional médico: a aprendizagem na Atenção Básica de Saúde. Rev Bras Educ Med. 2007; 31(1):52-9..

Mechanisms and strategies that not only foster the diagnosis and treatment of diseases but also promote the development of protagonism and autonomy of medical students, doctors and users with the care process are also established²⁴24 Ferreira R, Silva R, Aguer C. Formação do profissional médico: a aprendizagem na Atenção Básica de Saúde. Rev Bras Educ Med. 2007; 31(1):52-9.^,2525 Ministério da Saúde (BR). Clínica ampliada, equipe de referência e projeto terapêutico singular. 2a ed. Brasília: Ministério da Saúde; 2008.. Additionally, a strong bond among these agents is also facilitated, enabling the development of horizontal relationships based on mutual respect:

Based on this scope, we move towards a curricular proposition that values life, aiming at improving the quality of healthcare by developing strategies that also strengthen health promotion and disease prevention actions that are essential to medical practice. With this in mind, there is an attempt to change from a paradigm based on (pain) indicators focused on negative health effects and on the biomedical and healing point of view to a structure of indication focused on life conditions and social contexts in which social life production and reproduction processes are developed²⁶26 Breilh H. De lavigilancia convencional al monitoreo participativo. Cienc Saude Colet. 2003; 8(4):937-51..

The incorporation of these propositions in the curricular matrix of medical courses resignifies the current education model. The current model prioritizes hospitals as the scenario of practice, promoting a mismatch among guidance from public policies¹⁰10 Ministério da Saúde (BR). Secretaria de Gestão do Trabalho e da Educação na Saúde. Programa Mais Médicos - dois anos: mais saúde para os brasileiros. Brasília: Ministério da Saúde; 2015.

11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014.^-1212 Portaria Interministerial nº 2.101, de 3 de Novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde - para os cursos de graduação em Medicina, Enfermagem e Odontologia. Diário Oficial da União. 3 Nov 2005., the country’s social needs and primary care strengthening²⁷27 Oliveira NA, Alves LA. Ensino médico, SUS e início da profissão: como se sente quem está se formando? Rev Bras Educ Med. 2011; 35(1):26-36.. On the other hand, this incorporation promotes praxis based on a permanent and inseparable process of reflection and action combined with interactions and determinations from the concrete social world where students and users of health services mutually help each other in order to build a socially-based shared knowledge with social return²⁸28 Ferreira MJM, Rigotto RM. Contribuições epistemológicas/metodológicas para o fortalecimento de uma (cons)ciência emancipadora. Cienc Saude Colet. 2014; 19(10):4103-11., as shown below: "In terms of education, professional competencies that promote autonomy and intellectual independence with social responsibility are, essentially, unmistakenly important for the education of good doctors. (S4)

Therefore, it favors the creation of a curricular matrix that is fed by and that feeds social demands, that is based on the community’s morbimortality profile and that incorporates the challenge of responding to the population’s health needs. It adopts primary care as the priority care level to implement the suggested curricular changes, based on its ability to operationalize most of the competencies provided by the 2014 National Curricular Guidelines. Additionally, it is aligned to the policies that foster the development of this care level, taking into consideration the need to readapt and strengthen the education of human resources according to SUS needs¹⁰10 Ministério da Saúde (BR). Secretaria de Gestão do Trabalho e da Educação na Saúde. Programa Mais Médicos - dois anos: mais saúde para os brasileiros. Brasília: Ministério da Saúde; 2015.

11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014.

12 Portaria Interministerial nº 2.101, de 3 de Novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde - para os cursos de graduação em Medicina, Enfermagem e Odontologia. Diário Oficial da União. 3 Nov 2005.

13 Severino AJ. Metodologia do trabalho científico. São Paulo: Cortez; 2007.^-1414 Ibiapina IMJM, Bandeira HMM. Pesquisa-ação crítica: origem e desenvolvimento do campo teórico-prático. In: Ibiapina IMJM, Bandeira HMM, Araújo FAM. Pesquisa colaborativa: multirreferenciais e práticas convergentes. Piauí: EDUFPI; 2016..

Therefore, it is necessary to develop strategies that are able to connect students to primary care in an organized and systematic way throughout the course. However, the material conditions were pointed out as weak elements:

Regarding health management, the new 2014 National Curricular Guidelines guide medical courses to promote the community’s wellbeing by valuing life through general, propositional and problem-solving doctors. In order to do so, the guidelines encourage the creation and implementation of intervention plans that support creativity and innovation¹¹11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014.. However, the seminars’ participants indicated these elements as critical and incipient:

Despite the challenges, initiatives have been developed in order to foster the medical students’ commitment to advocate for citizenship, human dignity and right to health. Therefore, collaborative work and teamwork, aligned to the development of teaching and learning scenarios based on professional and compassionate ethics, are important tools to resignify healthcare:

Therefore, the potentiality of scenarios of practice and collectivity to the development of a commitment with quality, comprehensive care and continuity of care is acknowledged. Additionally, the perspective of users, family, students and professionals is included, helping with a collaborative health work. All these processes contribute to prioritizing problems in order to improve the work process and healthcare’s organization. Therefore, there is an advance towards the search for a collective construction of the health system based on human, ethical, compassionate and healthcare principles¹¹11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014..

Collective health as the basis for the creation of a new curricular matrix of medical courses

The connection between the new 2014 National Curricular Guidelines and the theoretical and conceptual framework of Collective Health enables a deeper analytical and reflective analysis of its interrelations. It also contributed to subsidize the proposition of a new curricular matrix in the School of Medicine of Universidade Federal do Ceará.

The knowledge acquired by teachers and technicians during the seminars enabled a paradigm approximation among the National Curricular Guidelines’ competency areas¹¹11 Ministério da Educação (BR). Resolução nº 3, de 20 de Junho de 2014. Diretrizes curriculares nacionais do curso de graduação em medicina. Brasília: Ministério da Educação; 2014., the structural fundamentals of Collective Health⁶6 Nunes E. Saúde coletiva: uma história recente de um passado remoto. In: Campos GWS, Bonfim JRA, Minayo MCS, Akerman M, Drumond Júnior M, Carvalho YM, organizadores. Tratado de saúde coletiva. São Paulo: Hucitec; 2012. p. 17-37. and the curricular components of medical courses²⁹29 Comissão de Reforma Curricular da Universidade Federal do Ceará/Faculdade de Medicina. Projeto pedagógico: currículo do curso de medicina. Fortaleza: Imprensa Universitária; 2001.. Aimed at fostering the importance of a comprehensive and human care in medical education, a deeper integration among the curricular contents was sought throughout the modules. Additionally, a transversal insertion of communication skills components and of the relationship between doctors and patients was provided, being also included in the syllabus of some modules throughout the course.

The schematic representation of the new curricular matrix as a result of the seminars contains the approach of each competency area of the National Curricular Guidelines throughout the course, connected with the three structural axes of Collective Health. In the beginning of education, students go through an introductory process (I) in the three areas. Throughout the semesters, main focuses (F), and theoretical and practical deeper studies (TPS) are guided in connection with the modules’ content. In residency, these three areas return with a deeper practical focus (PF). Components related to Epidemiology; Social and Human Sciences; and Politics, Planning and Management transversally feed the content in all semesters.

The curricular matrix’s schematic representation can be seen in Figure 2 below:

The layout of a curriculum shows how an educational institution sees itself in the world, its role, the relationships it establishes, its choice of interlocutors and how it produces and conceives knowledge. Additionally, particularly in schools of Medicine, it shows the conception of health and of the doctor’s role in society²²22 Feuerwerker L. Além do discurso de mudança na educação médica: processos e resultados. São Paulo: Hucitec; 2002..

In this sense, the suggested curricular matrix tends towards a redesign:

It resignifies primary healthcare as a preferential scenario for the development of knowledge, skills and attitudes of doctors.

It fine-tunes the development of its praxis according to the most prevailing health demands of families and communities.

It suggests the establishment of longitudinal and transversal relationships among the 2014 National Curricular Guidelines’ competency areas, basic Collective Health cores and curricular components offered during the course:

Nobody disagrees that curriculum is important. However, we have to discuss the strategies we can use to achieve our objectives with the students: educate doctors of people, not of diseases! Curricula should be used to educate, not misshape. We should not philosophically sicken our students. (S1)

Therefore, the curriculum is now seen not as an end, but as a means on which different pedagogical strategies are based. The inseparability of teaching, research and extension as the foundation of a solid education should also be considered in order to prioritize care for concrete health needs of the population. It is necessary to permanently insert students into primary care, adopting it as a concrete scenario for the development of practical activities in contexts of growing complexity and responsibility¹1 Amoretti R. A educação médica diante das necessidades sociais em saúde. Rev Bras Educ Med. 2005; 29(2):136-46..

The insertion of students in primary healthcare also contributes to strengthening Family Health Strategy, since it helps in the dialog between services and universities. Therefore, it potentializes the flow so that the academic triad of teaching, research and extension can work in the development of technologies and tools that can provide a greater capability to address the challenges in the service’s daily routine.

Additionally, strengthening the articulation among teaching, service and community enables the creation of scenarios that favor the exchange of knowledge, in which the complexity in the daily work routine of health services feeds discussions and enriches the teaching and learning process in undergraduate courses. Through these experiences, students understand the difficulties and possibilities of combined health practices, experiencing the real SUS routine.

Final remarks

Planning the education of human resources in health in order to meet SUS needs remains a current challenge, particularly in Medicine. In this sense, government initiatives have been instituted in order to redesign the curricular structure of medical courses, contributing to a professional education that can effectively meet the most prevailing health demands of the population.

Under the scope of this process, the new 2014 National Curricular Guidelines of medical courses were instituted. They aim at strengthening primary healthcare, resignifying it as a strategic space for medical education. Additionally, they value the potentialities of Collective Health, incorporating its paradigmatic elements in the proposition of articulated competency areas in order to foster a comprehensive healthcare.

In this context, the suggested curricular matrix aims at encouraging graduates to understand determinants and relationships between diseases and people’s way of living and work. In order to do so, it values the teaching-service-community triad as a strategy that can provide changes in people, family and community’s healthcare.

The need to carefully listen to all involved agents is evident, from the creation of new matrices in the curriculum of medical education to a dialog that is closer to the public health system.

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