Abstract

Introduction

Medical care essentially implies human relations, bonds and intimacy; therefore, it cannot be detached from the affective dimension of existence. However, the technological boom in recent decades and the subsequent enhancement of medical procedures were followed by gradual disassociation from human interaction in medical “doing”. Scientific knowledge and technical skills overshadowed the passion and compassion inherent to humane caregiving practices.

The traditional medical education model was created in 1910 by Abraham Flexner, an American educator who suggested associating medical schools with hospitals in order to qualify and standardize education. As a consequence, health theory and practice were divided into several specializations, and education was centered on the “anatomo-clinical” scientific method ¹1. Itikawa FA , Afonsoi DH , Rodrigues RD , Guimarães MAM . Implantação de uma nova disciplina à luz das diretrizes curriculares no curso de graduação em medicina da Universidade do Estado do Rio de Janeiro . Rev Bras Educ Med . 2008 ; 32 ( 3 ): 324 - 32 . .

Medical education became gradually guided by “a set of structural principles: mechanisms, ‘biologism’, individualism, specialization, exclusion of alternative therapies, emphasis on curative care, concentration of resources and by the ‘technification’ of medicine” ²2. Silva J, Alves AG, Almeida C. Modelos assistenciais em saúde: desafios e perspectivas. In: Morosini MVGC, Corbo ADAC, organizadores. Modelos de atenção e a saúde da família. Rio de Janeiro: EPSJV/Fiocruz; 2007 . p. 27-41. (p.325).

This scientific medical model fell into crisis in the second half of the 20th (twentieth) century. Its inefficiency was exposed by the growing need of investments, high costs and poor solutions for the health needs of the general population. Therefore, the doctor-patient relationship model isbased on the hospitalization process principles, such as listening to patient’s problems, humanism and the inseparable body/mind unity. ¹1. Itikawa FA , Afonsoi DH , Rodrigues RD , Guimarães MAM . Implantação de uma nova disciplina à luz das diretrizes curriculares no curso de graduação em medicina da Universidade do Estado do Rio de Janeiro . Rev Bras Educ Med . 2008 ; 32 ( 3 ): 324 - 32 . , ³3. Amoretti R. A educação médica diante das necessidades sociais em saúde. Rev Bras Educ Med. 2005 ; 29(2):136-46.

Pedagogical strategies derived from this historical path due to Flexner’s model inadequacies for medical education. Back to the 1950s, George Miller, from the State University of New York, stood out among the American pioneers in pedagogical endeavors. After systematic research, Miller proposed the beneficial association with pedagogy and developed strategies to qualify teaching and learning processes in medical schools, the so-called “teaching medical teachers to teach” ⁴4. Norman G . Fifty years of medical education research: waves of migration . Med Educ . 2011 ; 45 ( 8 ): 785 - 91 . (p.788).

In the early 20 ^th century, political and academic circles reinforced the consensus that the traditional medical training approach needed changes and adjustments, so that medical education could properly meet the needs of social settings where qualified doctors performed their jobs ⁵5. Oliveira GS, Koifman L. Integralidade do currículo de medicina: inovar/transformar, um desafio para o processo de formação. In: Marins JJN, Rego S, Lampert JB, Araújo JGC, organizadores. Educação médica em transformação: instrumentos para a construção de novas realidades. São Paulo: Hucitec, Rio de Janeiro: Associação Brasileira de Educação Médica; 2004 . , ⁶6. Hamamoto Filho PT , Santos Filho CA , Abbade JF , Peraçoli JC . Produção científica sobre educação médica no Brasil: estudo a partir das publicações da Revista Brasileira de Educação Médica . Rev Bras Educ Med . 2013 ; 37 ( 4 ): 477 - 82 . .

Brazilian curricular changes - underway since 2001 - indicate the need of training doctors to assimilate the biological, psychological, social and environmental dimensions of the health-disease process; and to have a critical reflective approach to multi-professional health teams. Hence, teaching methodologies must encourage students to participate in knowledge production by associating medical-academic training with social health needs based on the Brazilian National Health System (SUS) principles ⁷7. Brasil. Ministério da Educação. Conselho Nacional de Educação. Resolução CNE/CES nº 3, de 20 de Junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação de Medicina e dá outras providências. Diário Oficial da União. 23 Jun 2014. .

The modern era reflects the concern with challenges yet faced by medical education. The pioneering Alma Ata International Conference held in Kazakhstan in 1978 ⁸8. Ministério da Saúde. Conferência Internacional sobre Cuidados Primários de Saúde: Declaração de Alma-Ata, 1978. Brasília, DF: Ministério da Saúde; 2004. suggested that the world should define primary care as a priority and aim at providing “Health for All in Year 2000”. One of the aforementioned challenges lied on retrieving the old “family doctor” spirit. In order to reach this goal, medical teachers should encourage the development of overall skills and the ability to understand diseases based on their biopsychosocial context ⁹9. Del Giglio A . Medicina e humanismo . Rev Assoc Med Bras . 2007 ; 53 ( 3 ): 191 - 2 . .

The National Curriculum Guidelines (NCGs) for the 2014 Medical Graduation Course, by the Ministry of Education and Culture established overall humanitarian medical education based on the following terms: “professionals qualified to work at different healthcare levels, with responsibility, and committed to defend citizenship, human dignity and universal access to health” ⁷7. Brasil. Ministério da Educação. Conselho Nacional de Educação. Resolução CNE/CES nº 3, de 20 de Junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação de Medicina e dá outras providências. Diário Oficial da União. 23 Jun 2014. .

NCGs aim at ensuring the flexibility, creativity and responsibility of discipline matrix proposals from higher education institutions. The comprehensiveness principle is a way to achieve proper healthcare, since it takes into account the source of suffering. Students should be able to follow a non-reductionist approach in order overcome explicit complaints and to not suppress patients’ suffering ³3. Amoretti R. A educação médica diante das necessidades sociais em saúde. Rev Bras Educ Med. 2005 ; 29(2):136-46. , ⁵5. Oliveira GS, Koifman L. Integralidade do currículo de medicina: inovar/transformar, um desafio para o processo de formação. In: Marins JJN, Rego S, Lampert JB, Araújo JGC, organizadores. Educação médica em transformação: instrumentos para a construção de novas realidades. São Paulo: Hucitec, Rio de Janeiro: Associação Brasileira de Educação Médica; 2004 . , ⁷7. Brasil. Ministério da Educação. Conselho Nacional de Educação. Resolução CNE/CES nº 3, de 20 de Junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação de Medicina e dá outras providências. Diário Oficial da União. 23 Jun 2014. .

Working based on the Comprehensiveness and Expanded Clinic principles means fostering new “doings”. The term “psychosocial” defines practices aimed at replacing the dominant psychiatric care model, so far ¹⁰10. Da Costa-Rosa A . A instituição de saúde mental como dispositivo social de produção de subjetividade . Estud Psicol (Campinas). 2012 ; 29 ( 1 ): 115 - 26 . .

Work aspirations are supposed to be guided by values such as professional autonomy and protagonism, co-responsibility, solidarity bonds, and collective participation in management processes ¹¹11. Amarante P , Torre EHG . Loucura e diversidade cultural: inovação e ruptura nas experiências de arte e cultura da Reforma Psiquiátrica e do campo da Saúde Mental no Brasil . Interface (Botucatu). 2017 ; 21 ( 63 ): 763 - 74 . . However, this approach is challenged by medical schools’ disregard to mental health issues ⁶6. Hamamoto Filho PT , Santos Filho CA , Abbade JF , Peraçoli JC . Produção científica sobre educação médica no Brasil: estudo a partir das publicações da Revista Brasileira de Educação Médica . Rev Bras Educ Med . 2013 ; 37 ( 4 ): 477 - 82 . .

Universities have suggested the holistic approach, which prioritizes student-oriented training and vertically-aligned mental health content throughout discipline matrix, as the alternative to mental health disregard. Healthcare should go beyond the mind and body dichotomy, as well as take into consideration disease etiologies such as: emotional struggles, doctor-patient relationship, and environmental and social factors, since mental health struggles are prevalent across society. Such etiologies substantiate the importance of exposing students to a wide range of mental health conditions ¹²12. Rêgo C , Batista SH . Desenvolvimento docente nos cursos de medicina: um campo fecundo . Rev Bras Educ Med . 2012 ; 36 ( 3 ): 317 - 24 . , ¹³13. Cliquet MB , Rodrigues CIS . Grupo tutorial e a saúde mental no ensino médico . Rev Bras Educ Med . 2016 ; 40 ( 4 ): 591 - 601 . .

Students must be in touch with psychologically ill patients in healthcare settings since the first years of college in order to achieve comprehensive care. Therefore, the aim of the present study was to assess students’ educational dimension in mental health settings through photographs and focus group discussions.

Methodological path

The present study was based on social psychology theories focused on social phenomena; likewise, this type of approach enlightens the meanings and intentions separating social from natural phenomena. The aforementioned theories favor the comprehensive approach, rather than the cause-and-effect one, in interpretations about psychosocial phenomena ¹⁴14. Minayo MCS . O desafio do conhecimento: pesquisa qualitativa em saúde . 14a ed. São Paulo, Rio de Janeiro: Hucitec, ABRASCO; 2014. .

Photography is closely linked to qualitative research strategies because it helps describing events and understanding their subjective aspects. Moreover, photographs can be inductively understood ¹⁵15. Bogdan CR, Biklen KS. Investigação qualitativa em educação: uma introdução à teoria e aos métodos. Porto: Porto Editora; 1994 . (Coleção Ciências da Educação). ; images captured in photos enable the study about life aspects not expressible by words, alone.

The Photovoice method, which was chosen and adapted for the present research, was developed by Wang et al. ¹⁶16. Wang CC , Burris MA , Xiang YP . Chinese village women as visual anthropologists: a participatory approach to reaching policymakers . Soc Sci Med . 1996 ; ( 42 ): 1391 - 400 . in the mid 1990s. It allowed people to portray and share community experiences through a specific photography technique. The method gives voice to people since it lies on providing cameras to citizens so they can become reporters and the potential catalysts of political and social changes within their own communities ¹⁶16. Wang CC , Burris MA , Xiang YP . Chinese village women as visual anthropologists: a participatory approach to reaching policymakers . Soc Sci Med . 1996 ; ( 42 ): 1391 - 400 . , ¹⁷17. Wang CC , Burris MA . Photovoice: concept, methodology, and use for participatory needs assessment . Health Educ. 1997 ; 24 ( 3 ): 369 - 87 . .

The critical pedagogy of Paulo Freire (1970 apud Wang ¹⁶16. Wang CC , Burris MA , Xiang YP . Chinese village women as visual anthropologists: a participatory approach to reaching policymakers . Soc Sci Med . 1996 ; ( 42 ): 1391 - 400 . ) was one of the essential ideas underlying the theoretical body of this methodology. He advocated that “every human being, no matter how “ignorant” or “immersed in the culture of silence”, is able to hold a critical and dialectic outlook of the world around it and of the relationships it maintains” (emphasis added).

Furthermore, Photovoice is defined as a participatory action research approach that encourages people to take photographs of their experiences and discuss them as members of a particular community or group. Hence, the general population has the chance to hold accountable authorities and researchers through photographs and accompanying reports ¹⁷17. Wang CC , Burris MA . Photovoice: concept, methodology, and use for participatory needs assessment . Health Educ. 1997 ; 24 ( 3 ): 369 - 87 .

18. Wang CC , Red-Wood Jones A . Photovoice ethics: perspectives from flint Photovoice . Health Educ Behav . 2001 ; 28 ( 5 ): 560 - 72 . - ¹⁹19. Wang CC , Cash J , Powers LS . Who knows the streets as well as the homeless? Promoting per-sonal and community action through Photovoice . Health Promot Pract . 2000 ; 1 ( 1 ): 81 - 9 . .

Photovoice has been applied not only to community research, but also to several knowledge fields for more than two decades. The literature has only few examples of projects that have used photographs as the tool to set broader dialogues and boost social change in the health and education fields. The growing expansion of Photovoice supported the original remark by Wang and Burris ¹⁷17. Wang CC , Burris MA . Photovoice: concept, methodology, and use for participatory needs assessment . Health Educ. 1997 ; 24 ( 3 ): 369 - 87 .: the reflective discussion about photographs encourages critical dialogues about specific issues of interest to researchers ²⁰20. Novak D . Democratizing qualitative research: photovoice and the study of human communication . Commun Methods Meas . 2010 ; 4 ( 4 ): 291 - 310 . .

A study was carried out in Canada from 2010 to 2011 with four family and community medicine residents, two medical supervisors and two researchers (an anthropologist and a medical professor). The residents had to photograph their primary health care routine, choose five photographs portraying the topic and attend an interview and debriefing sessions with the researchers ²¹21. Loignon C , Boudreault-Fournier A , Truchon K , Labrousse Y , Fortin B . Medical residents reflect on their prejudices toward poverty: a photovoice training project . BMC Med Educ . 2014 ; 14 :1050-62. .

A 2016 European essay focused on investigating the contributions of Photovoice to education; based on its conclusion, this method has benefits such as access to settings and subjective experiences that are harder to be understood through retrospective or observational research; student engagement to research process; real academic experiences; and reflection on teaching and learning processes ²²22. Massengale KEC , Strack RW , Orsini MM , Herget J . Photovoice as pedagogy for authentic learning . Pedagogy Health Promot . 2016 ; 2 ( 2 ): 117 - 26 . .

The herein adopted focus group method aimed at giving meaning to photos taken by the participants and at broadening the dialogue between facilitator and participants.

Focus groups are particularly useful for reflecting upon social and cultural realities because it helps accessing experiences, meanings, interpretations, behaviors, opinions, knowledge and beliefs given its qualitative profile ²³23. Wilkinson S . Focus group methodology: a review . Int J Soc Res Methodol . 1998 ; 1 ( 3 ): 181 - 203 . . The greatest advantage of data collection through focus groups lies on the chance to form opinions and behaviors through discussions with others ²⁴24. Krueger RA , Casey MA . Focus groups: a practical guide for applied research . Califórnia: Sage publications; 2014. .

The present study was carried out between 2017 and 2018, data were collected in a rural city in São Paulo State, which presented estimated population of 344,704 people in 2016. A private medical school was launched in the city in 2012. The pedagogical school project embraced active teaching methodologies and followed the NCG guidelines ⁷7. Brasil. Ministério da Educação. Conselho Nacional de Educação. Resolução CNE/CES nº 3, de 20 de Junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação de Medicina e dá outras providências. Diário Oficial da União. 23 Jun 2014. . The aim of the project was to prepare professionals to act according to scientific and humane values. The theoretical-practical discipline known as “Introduction Program for Family Health Education (IPFHE)” is taught from first to eighth semester in order to introduce students to public health networks and municipal hospitals through progressive complexity tasks.

Participants featured in Table 1 were chosen by convenience. A group of six IPFHE students enrolled in the 6th semester of medical school was invited to participate. After signing the Informed Consent Form (ICF), they attended two meetings for technical training. They were asked to focus and to take photos with their smartphone cameras to portray their daily lives as mental health care students.

Results and discussion

The project was submitted to the Human Research Ethics Committee, according to Decision N. 466/12. It was registered under CAAE N. 68579917.0.0000.5495 and received approval N. 2,261. 870.

The group took 32 photos, in total. Participants were asked to choose the two most significant photos and to assign a title and to give meanings to them at the initial interview. The representative photos were discussed in two focus group meetings led by the main researcher. The reports and collective voices accompanying the exhibitions were digitally recorded and fully transcribed.

The coverage of the Photovoice method brought challenges to researchers who used creative handicraft work as research resource applied to the images that had symbolic potential and ability to capture emotions impossible to be expressed in words.

The Sensory Interpretation Method ²⁵25. Gomes R. Análise e interpretação de dados de pesquisa qualitativa. In: Minayo MCS, organizador. Pesquisa social: teoria, método e criatividade. Petrópolis: Vozes; 2007 . p. 79-108. was used to interpret the produced material. The interpretation process was defined as follows: thoroughly analyzing the collected dataand identifying themes, problematizing and interpreting meanings underlying the narratives and, finally, providing conclusion.

The research material was divided into two themes: Introduction to Health Care Practice and Medical Education in Action, which were intertwined and applied to mental health care settings in Franca City. Comprehensive dialogue was considered the basis of Medical Education in Action; therefore, the themes were developed based on the relevant literature of their scientific field.

Photographs: images and reflections

Introduction to health care practice and medical education in action

The expansion of learning spaces beyond specialty hospitals is one of the ideas to reshape the educational model; this expansion implies new work experiences with humanitarian approaches and the development of interdisciplinary curriculums. Knowledge production, professional training and service provision must be deemed inseparable; accordingly, the relationship between universities and different social groups must be redefined in order to build a new and relevant social setting committed to overcoming inequalities and to consistently fulfill social demands ⁶6. Hamamoto Filho PT , Santos Filho CA , Abbade JF , Peraçoli JC . Produção científica sobre educação médica no Brasil: estudo a partir das publicações da Revista Brasileira de Educação Médica . Rev Bras Educ Med . 2013 ; 37 ( 4 ): 477 - 82 . , ²⁶26. Feuerwerker LCM. Cuidar em saúde. In: Rocha CMF, Pinto HA, Andrade LR, Feuerwerker LCM, Santos L, Bilibio LFS, et al. Organizadores. VER-SUS Brasil: cadernos de textos. Porto Alegre: Rede Unida; 2013 . p. 43-57. .

NCGs provide a broader definition of health. The combination of courses into integrated discipline matrices is a desirable option to overcome disciplinary models since they add relevant and inspiring themes to these matrices frameworks. Therefore, the association of learning environments with health services and social settings of professional training can overcome the gap between theory and practice ²⁶26. Feuerwerker LCM. Cuidar em saúde. In: Rocha CMF, Pinto HA, Andrade LR, Feuerwerker LCM, Santos L, Bilibio LFS, et al. Organizadores. VER-SUS Brasil: cadernos de textos. Porto Alegre: Rede Unida; 2013 . p. 43-57. , ²⁷27. Silveira TTJ , Palko SNL , Staevie BR . Apostas de mudança na educação médica: trajetórias de uma escola de medicina . Interface (Botucatu). 2017; 21 ( 60 ): 177 - 88 . .

Context 1: psychiatric hospital

This image opened the theme Psychiatric Hospitalization, which was portrayed by the first photographs chosen during focus group discussions at the Psychiatric Hospital. According to the reports, this and other images seemed to convey an evident claustrophobic tension. The raw display may have been a way to bring up topics often left out of psychiatry manuals: patient’s multiple layers of suffering and health professionals’ sense of helplessness.

All voices agreed that the Psychiatric Hospital is no longer a place in time and space. The introduction of students to private hospital spaces is the strategy to sensitize them for academic knowledge production; however, experiences must be given a voice, listened to and transformed so that their potential can be fulfilled. All participants called for the need of going beyond the first impact and of thinking about assistance on a broader perspective, since the “health vs disease” model is unsuitable for grasping the overall dimension of mental illness. Students who come across this unknown reality are invited to understand disease beyond their nosological features; they assess the suffering, inabilities and boundaries of a health care model that calls for “Reformation” ²⁵25. Gomes R. Análise e interpretação de dados de pesquisa qualitativa. In: Minayo MCS, organizador. Pesquisa social: teoria, método e criatividade. Petrópolis: Vozes; 2007 . p. 79-108. .

Practices based on the comprehensiveness and expanded clinic principles are tools to build new ethics in mental health care. The “medicalized psychiatric hospital-centered” model has been gradually replaced by the psychosocial model ²2. Silva J, Alves AG, Almeida C. Modelos assistenciais em saúde: desafios e perspectivas. In: Morosini MVGC, Corbo ADAC, organizadores. Modelos de atenção e a saúde da família. Rio de Janeiro: EPSJV/Fiocruz; 2007 . p. 27-41. , ⁵5. Oliveira GS, Koifman L. Integralidade do currículo de medicina: inovar/transformar, um desafio para o processo de formação. In: Marins JJN, Rego S, Lampert JB, Araújo JGC, organizadores. Educação médica em transformação: instrumentos para a construção de novas realidades. São Paulo: Hucitec, Rio de Janeiro: Associação Brasileira de Educação Médica; 2004 . , ¹⁰10. Da Costa-Rosa A . A instituição de saúde mental como dispositivo social de produção de subjetividade . Estud Psicol (Campinas). 2012 ; 29 ( 1 ): 115 - 26 . . This replacement implies levelling the old hierarchy of knowledge, cooperation among care givers and favoring human-to-human knowledge (‘unknown’ and unconscious) over “encyclopedic knowledge” ¹⁰10. Da Costa-Rosa A . A instituição de saúde mental como dispositivo social de produção de subjetividade . Estud Psicol (Campinas). 2012 ; 29 ( 1 ): 115 - 26 . .

The second photo representing this scenario did not even look like it was taken in the same claustrophobic and hostile place as the previous one. The sequence of themes proposed by the focus group pointed towards the double potential of the initial shock. The same experience can either overwhelm and render its essence unfeasible, or expand comprehension possibilities and foster students’ cognitive and emotional growth when they discuss and give meaning to their experience.

Ayres ²⁸28. Ayres JRCM . O cuidado, os modos de ser (do) humano e as práticas de saúde . Saude Soc . 2006; 13 ( 3 ): 16 - 29 . sheds light on the caregiving issues; the author addresses it as a health practice and describes it as the attitude of launching yourself into the world, but constantly redefining yourself and the world. The author states that caregiving can be therapeutic if its existential meaning is actively sought after. Participants recovered the balance of mental health care, and differences became familiar, when they put themselves in the shoes of others (“can any of us develop a mental illness tomorrow and deal with it?”). The close contact with patients rose interest in the existential sense of physical and mental illnesses; hence, students were able to find out possible health recovery practices that could help life rescueing.

Medical career as a choice implies responsibility and, consequently, it demands systematic reviews of concepts and values. The medical career is based on the sense of humanization, which is defined as the reason of each individual to be involved in the health provision process ⁹9. Del Giglio A . Medicina e humanismo . Rev Assoc Med Bras . 2007 ; 53 ( 3 ): 191 - 2 . . Accordingly, the literature adresses psychosocial care as an ethical, theoretical and political reference of the Psychiatric Reform movement in Brazil, as well as a realistic approach to mental health care ²⁹29. Vasconcellos VC. A dinâmica do trabalho em saúde mental: limites e possibilidades na contemporaneidade e no contexto da reforma psiquiátrica brasileira. Rio de Janeiro: Escola Nacional de Saúde Pública, Fundação Oswaldo Cruz; 2008 . .

The connection between rationality and sensitivity seems a possible measure to redefine health and illness; however, this connection is challenged by theoretical and political tensions. Therefore, effective public health management should be achieved through speeches and practices leading to new and broader approaches in scientific knowledge ⁸8. Ministério da Saúde. Conferência Internacional sobre Cuidados Primários de Saúde: Declaração de Alma-Ata, 1978. Brasília, DF: Ministério da Saúde; 2004. , ³⁰30. Giovannini PE, Paiva Neto JR, Silva JV, Cunha ATR, Maia AMLR, Rodrigues T . Promoção da saúde em campos de estágio para a formação médica . Rev Bras Educ Med . 2018 ; 42 ( 1 ): 181 - 9 . .

Context 2: therapeutic community

Chemical addiction can be treated within “nonviolent” contexts, in healthy environments suitable for rehabilitation. This concept has broadened students’ outlook on dignified care to vulnerable patients subjected to psychoactive substances. On the other hand, some of these students’ speeches could be considered thoughtless and disregarded from others; saying “needs to think about their choices”, sounds like blaming the victim and disregarding several other layers of addiction. Confined addicts cause less discomfort than homeless addicts; thus, society does not understand “clean” as a threat.

Basaglia ³¹31. Basaglia F. A instituição negada: relato de um hospital psiquiátrico. Rio de Janeiro: Graal; 1985 . (Obra original em Italiano 1968). mentions institutional violence in closed institutions, the author explains how they steal the freedom and recovery chances of hospitalized patients. Violence and exclusion are “justified” by an alleged educational and hierarchical separation of those who have power from the ones who do not. Human, egalitarian and welfare rights are disregarded by such separation.

According to Basaglia ³¹31. Basaglia F. A instituição negada: relato de um hospital psiquiátrico. Rio de Janeiro: Graal; 1985 . (Obra original em Italiano 1968). , the Psychiatric Reform in Brazil brought about changes in the mental health context, especially in Psychiatric Hospitals, by developing alternatives to inpatient care. However, confinement remains the preferred option for alcohol and drug addicts; although this context is not as hostile as the ones addressed above, social exclusion remains blatant.

The mediated group formed opinions: When students looked more deeply into the “perfect” landscape, cleanliness and organization, they saw the negative side of hospitalization and expressed new thoughts (“Is there no other way?”; “It’s bad to be isolated”). A dialogue process is established by looking at photos, and by talking and listening about them. The meeting of voices in a lively and practical interaction gives meaning to experiences and theories. These are important steps towards “being a doctor”, complex human issues require the ability to see beyond physical laws and biological reductionism. After all, students allowed themselves to embrace the overall dimension of mental health care.

Edgar Morin ³²32. Morin E. Introdução ao pensamento complexo. Lisboa: Instituto Piaget; 2001 . (XX century) claims that knowledge is built through dialogue, which makes comprehension go beyond surface and towards the essence. He proposes the redefinition of thought and invites readers to abandon the ruins of the building constructed under the pillars of fragmentation, hyperspecialization and reduced knowledge. Morin suggests that educational “folders” must be opened so that knowledge can be thoroughly explored.

Introduction to real, dynamic and complex contexts in the first years of medical school is key to achieve mindsets able to overcome narrow simplifications. Ethical-humanitarian medicine requires the applicability of complex thinking: the expression of unified and multiple ideas as a whole, and the elimination of simplistic, reductionist and disjunctive ideas.

Context 3: psychiatric emergency

The photo shows the façade of the building whose Psychiatric Emergency was visited by the participants. The focus group went silent and hesitated to speak up at the moment the photo was taken.

Life stories like Guilherme’s seem to be hidden in the untouchable corners of memory, where everything hard and painful to be processed is isolated. Only the facilitator could help rescuing the story, so that details and underlying suffering in the patient’s report could emerge.

Such life stories make students see a broader health care concept that includes not only the role of patients, but also the role of family members, teams and health services. Thus, the core of medical practice, historically supported by biological and curative knowledge, changes into a universe of health promotion and prevention actions. Such actions encompass the comprehension of social determinants and the interaction of health services with different societal levels and settings ²⁸28. Ayres JRCM . O cuidado, os modos de ser (do) humano e as práticas de saúde . Saude Soc . 2006; 13 ( 3 ): 16 - 29 . .

Disease-oriented medicine proves to be insufficient to provide the care demanded by many “Guilhermes”. Standards need to be challenged, and society must stop blaming victims as the only individuals accountable for their own choices. Brazilian discipline matrices must include teachers, managers and SUS network professionals sharing different traits and qualifications, for such inclusion could foster the interdisciplinarity and comprehensiveness targeted by medical professionals ³³33. McNair R , Griffiths L , Reid K , Sloan H . Medical students developing confidence and patient centredness in diverse clinical settings: a longitudinal survey study . BMC Med Educ . 2016 ; 16 :176. .

Medical education is supposed to comprise patient-oriented care including the following traits: recognition of patients’ ideas and emotions towards their illness; common goals between doctors and patients. Sharing decisions and responsibilities mean a new path and the great potential of modern medical measures ⁵5. Oliveira GS, Koifman L. Integralidade do currículo de medicina: inovar/transformar, um desafio para o processo de formação. In: Marins JJN, Rego S, Lampert JB, Araújo JGC, organizadores. Educação médica em transformação: instrumentos para a construção de novas realidades. São Paulo: Hucitec, Rio de Janeiro: Associação Brasileira de Educação Médica; 2004 . , ³³33. McNair R , Griffiths L , Reid K , Sloan H . Medical students developing confidence and patient centredness in diverse clinical settings: a longitudinal survey study . BMC Med Educ . 2016 ; 16 :176. .

Conclusion

Medical professionals belong to where the ‘other’ is; the main goal of medical education is to reach this ‘other’. Therefore, it is necessary to be present, to feel, to associate knowledge with action, to give life to experiences, to feel excitement, only then this medicine could make sense.

Medical education is supposed to be done by transit; Transitu , in Latin, refers to passage, movement. The permanent movement among knowing, doing and thinking is what motivates professionals to care about their job and to provide ethical-humanitarian care based on meaningful experiences. The transit between medical theory and practice raises awareness about the meaning-making process and the importance of connecting affective and cognitive dimensions for a good medical practice.

Medical competence is a complex term that encompasses cognitive, psychomotor and socio-affective learning, altogether. According to NCGs, the aim of skill acquisition is to provide humane, critical and thoughtful medical education, committed to social needs and aimed at providing comprehensive health care for human beings. Curricular activities must be enhanced in order to foster dialogue and to embrace the subjectivity of students throughout their educational journey.

Participants engaged in mental health care work in the city where there school is based in were able to think about their education and to express their thoughts. The process of leaving school to get in touch with reality proved to be a breeding ground for understanding theoretical concepts seemingly empty and unsupportive for “doctors-to-be” ^ccDonald Woods Winnicott (1896-1971). . The photographed, reported and discussed experience brought life to education by taking students closer to the ‘human’ in them and in others.

References

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