Abstract

Introduction

The Flexnerian model had key influence on medical training in Brazil, based on the mechanization of care focused on individualism, specialization, technical, curative and hospital-centric approach¹1 Filisbino MA, Moraes VA. A graduação médica e a prática profissional na perspectiva de discentes. Rev Bras Educ Med. 2013; 37(4):540-8.. It is characterized by fragmentation of knowledge and distancing from a humanistic and comprehensive perspective²2 Cavalli LO, Rizzotto MLF. Formação dos médicos que atuam como líderes das equipes de Atenção Primária em Saúde no Paraná. Rev Bras Educ Med. 2018; 42(1):29-37..

In contrast to this, the Dawson Report in 1920 was considered the initial milestone of a modern conception of Primary Health Care (PHC), by proposing the organization of health systems in levels of care, including the primary level³3 Hone T, Macinko J, Millett C. Revisiting Alma-Ata: what is the role of primary health care in achieving the Sustainable Development Goals? Lancet. 2018; 392(10156):1461-72..

Brazilian PHC is the point of the Health Care Network (HCN) within the Brazilian National Health System (SUS), guided by internationally recognized essential and derived attributes for its structuring: first contact or gateway, longitudinality, comprehensiveness, and care coordination; family and community orientation, and cultural competence, respectively⁴4 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO Brasil, Ministério da Saúde; 2004..

The Family Health Strategy (FHS) emerged in Brazil as a privileged policy to reorient the care model and to structure the PHC, replacing the traditional model of care organization²2 Cavalli LO, Rizzotto MLF. Formação dos médicos que atuam como líderes das equipes de Atenção Primária em Saúde no Paraná. Rev Bras Educ Med. 2018; 42(1):29-37.. The FHS proposes coordinated actions at individual and collective levels from the perspective of integrality⁵5 Soratto J, Pires DEP, Dornelles S, Lorenzetti J. Estratégia saúde da família: uma inovação tecnológica em saúde. Texto Contexto Enferm. 2015; 24(2):584-92.. Training physicians prepared to work in the FHS has become a prerogative for the strengthening and expansion of PHC and for the implementation of the SUS as a new care model⁶6 Oliveira FP, Araújo CA, Torres OM, Figueiredo AM, Souza PA, Oliveira FA, et al. The More Doctors Program and the rearrangement of medical residency education focused on Family and Community Medicine. Interface (Botucatu). 2019; 23 Supl 1:e180008. doi: https://doi.org/10.1590/Interface.180008.
https://doi.org/10.1590/Interface.180008... ^,77 Leite APT, Correia IB, Chueiri PS, Sarti TD, Jantsch AG, Waquil AP, et al. Residência em Medicina de Família e Comunidade para a formação de recursos humanos: o que pensam gestores municipais? Cienc Saude Colet. 2021; 26(6):2119-30..

However, one of the persistent challenges for the consolidation of PHC in the country is the lack of specialized training of physicians for comprehensive care, along with deficiencies in the provision and retention of these professionals. Even in the face of recent initiatives, based on constitutional precepts for the organization of human resources in health by and for the SUS, such as the Mais Médicos Program (PMM in the Portuguese acronym), the number of specialists in Family and Community Medicine (FCM) is insufficient⁶6 Oliveira FP, Araújo CA, Torres OM, Figueiredo AM, Souza PA, Oliveira FA, et al. The More Doctors Program and the rearrangement of medical residency education focused on Family and Community Medicine. Interface (Botucatu). 2019; 23 Supl 1:e180008. doi: https://doi.org/10.1590/Interface.180008.
https://doi.org/10.1590/Interface.180008... .

The Residency in Family and Community Medicine (RFCM) is considered the highest standard of competency training for medical practice in the complexity of PHC, by developing competencies that mobilize knowledge, skills and attitudes under the biopsychosocial paradigm⁸8 Anderson MIP, Rodrigues RD. Formação de especialistas em Medicina de Família e Comunidade no Brasil: dilemas e perspectivas. Rev Bras Med Fam Comunidade. 2011; 6(18):19-20.^,99 Berger CB, Dallegrave D, Castro Filho ED, Pekelman R. A formação na modalidade Residência Médica: contribuições para a qualificação e provimento médico no Brasil. Rev Bras Med Fam Comunidade. 2017; 12(39):1-10.. It is also the training with the greatest potential to expand the scope of physician practice in PHC¹⁰10 Maranhão RR, Barreto ICHC, Andrade LOM, Vieira-Meyer APGF, Lima AL Jr. Como se relacionam o escopo de práticas profissionais, a formação e a titulação de médicos de Família e Comunidade? Interface (Botucatu). 2020; 24 Supl 1:e190640. doi: https://doi.org/10.1590/Interface.190640.
https://doi.org/10.1590/Interface.190640... .

It is in this context that the programs for Residency in Family and Community Medicine of Palmas in the state of Tocantins (Palmas-TO) are inserted. The RFCM of the Fundação Escola de Saúde Pública de Palmas (FESP) was created in 2014, currently has 20 places per year and since its inception has partnered with the program for RFCM of the Federal University of Tocantins (UFT) created in 2012 with 5 places per year, and since then they have a single coordination¹¹11 Prefeitura Municipal de Palmas. Secretaria da Saúde. Fundação Escola de Saúde Pública de Palmas. Sistema Integrado Saúde-Escola do SUS. Plano Integrado de Residência em Saúde (PIRS). Palmas: FESP; 2019..

Furthermore, through the Integrated Residency Program of FESP-Palmas, the RFCM program is integrated with the Multiprofessional Health Residency Program. FESP offers research scholarships that complement the residents’ income in a stimulating way¹¹11 Prefeitura Municipal de Palmas. Secretaria da Saúde. Fundação Escola de Saúde Pública de Palmas. Sistema Integrado Saúde-Escola do SUS. Plano Integrado de Residência em Saúde (PIRS). Palmas: FESP; 2019..

Residency programs in Palmas have their pedagogical projects effected by competence-based curriculum with the intent to homogenize FCM training in Brazil, and the use of active teaching-learning methodologies¹²12 Prefeitura Municipal de Palmas. Fundação Escola de Saúde Pública de Palmas. Programa da residência em medicina de família e comunidade. Palmas: FESP; 2019.^,1313 Trindade TG, Batista SR. Medicina de Família e Comunidade: agora mais do que nunca! Cienc Saude Colet. 2016; 21(9):2667-9..

Few studies describe the profile of former FCM graduates and their professional trajectory. A study with 129 graduates of RFCM in the state of São Paulo showed that most of the graduates (74%) worked in the area, and this permanence was more favorable among those who already wanted to be family doctors since graduation¹⁴14 Rodrigues EF, Forster AC, Santos LL, Ferreira JBB, Falk JW, Fabbro AL. Perfil e trajetória profissional dos egressos da residência em medicina de família e comunidade do estado de São Paulo. Rev Bras Educ Med. 2017; 41(4):604-14.. A study with residents and graduates of the state of Pernambuco highlighted that social commitment, aptitude for the area and the characteristics of the specialty were factors that influenced the choice for FCM¹⁵15 Rodrigues LGH, Duque TB, Silva RM. Factors associated with the choice of specializing in family medicine. Rev Bras Educ Med. 2020; 44(3):e078..

Until 2018, the RFCMs of UFT and FESP in Palmas have graduated 31 specialists. This research is anchored on the question of how the training of RFCM influenced the professional practice of their graduates and their performance regarding PHC attributes. Facing the expansion of places in the RFCM, and aware of gaps in the literature about the effects of this training⁷7 Leite APT, Correia IB, Chueiri PS, Sarti TD, Jantsch AG, Waquil AP, et al. Residência em Medicina de Família e Comunidade para a formação de recursos humanos: o que pensam gestores municipais? Cienc Saude Colet. 2021; 26(6):2119-30., we aimed to investigate the perception of graduates about the contribution of the RMFCs of the FESP and UFT of Palmas-TO for the formation and development of their current work process in PHC or in another area.

Methods

Exploratory and analytical study, using a qualitative approach focused on the perception of egresses from Family and Community Medicine Residency Programs in Palmas-TO.

A virtual questionnaire was applied, containing open questions divided into two blocks: the first aimed at graduates who continued working in Family and Community Medicine (FCM) after graduation and the second, to those who were working in another area (working in another specialty or attending another residency program).

The questions in the first block were about the decision to follow FCM when they enrolled in residency, the influence of the complementary grant from the municipality in the decision to opt for RFCM, the interference of residency in the decision to persist or not in the specialty, the evaluation of the graduates of their RFCM programs, as well as the existence or not of any issue that makes them unsatisfied with the specialty. These graduates were randomly coded and numbered as “EMF”.

The second block of questions referred to answers about the reason why the graduate is working in another area, the decision to take the RFCM first, the influence of the complementary grant from the municipality in the decision to choose to do RFCM before following another specialty, the graduates’ evaluation of the RFCM they took and the perception that initially taking the RFCM interfered or not in their performance in the current specialty. Here the graduates were randomly coded and numbered as “EOA”.

The questionnaire was initially submitted to a pilot study, which consisted of applying the instrument to 3 graduates from a RFCM not included in this study. After this stage, the electronic questionnaire underwent minimal changes in its structure.

All RFCM graduates from the Public Health School Foundation of the municipality of Palmas and the Federal University of Tocantins who completed their residency until February 2018 participated in the study, totaling thirty-one graduates. The participants were invited via e-mail, telephone contact, or through social networks (WhatsApp).

The questionnaire was made available via the Google Forms application, operated by the free Google Drive storage and synchronization service. The link to access the questionnaire was sent to the participants via e-mail, along with the Informed Consent Form (ICF) for acceptance and subsequent response to the questionnaire. A deadline of one month was set for the return of the responses, collected between January and February 2019.

The answers were gathered in a database, analyzed and interpreted through the Thematic Content Analysis, adopting a pre-analysis, in which the material was organized by floating reading; exploration of the material, by coding and defining categories, and finally the treatment of the results, where a deep interpretation of the meanings of the records presented was performed¹⁶16 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2013..

The research was submitted to the Research Ethics Committee of the University Center of Palmas of the Universidade Luterana do Brasil (CEULP-ULBRA) under CAAE number 98818718.6.0000.5516, following guidelines of Resolution No. 466/2012 of the National Health Council. The project was approved under opinion number 2.928.816.

Results and discussion

Four categories of analysis were empirically structured as a result from data interpretation: FCM training in the graduate work process, recognition and application of PHC attributes, potentials of FCM training and specialty challenges.

Most participants were female (77.4%), aged up to 30 years (51.6%), working in the same municipality of their residency training (58.1%) and remaining in the Family and Community Medicine area (61.3%) after completing residency (Table 1).

FCM training in the work process of the graduates

Graduates were unanimous in stating that attending this residency had contributed favorably to their education and work process. They emphasized that the methodology used allowed them to have a broader and better-grounded view of the assistance services and that they were trained to offer comprehensive and efficient care to the users of the health system.

Thus, a positive perspective was exposed in relation to the preparation and training provided to the egress through the RFCM. The concepts of ‘professional preparation’, ‘medical practice’ and ‘qualification to work in primary care’ are mentioned by different respondents, but in a repeated optimistic view that suggests satisfaction.

The findings of Castro et al.¹⁷17 Castro VS, Nóbrega-Therrien SM. Residência de Medicina de Família e Comunidade: uma estratégia de qualificação. Rev Bras Educ Med. 2009; 33(2):211-20. corroborate the perception of the graduates when they emphasize the significant and positive impact of the residency training process and its teaching-learning strategies needed for physicians who work in the FHS.

More than that, it is perceived that young physicians recognize the RFCM programs as an indispensable training stage after graduation, since medical courses in Brazil are still incipient in the preparation of professionals for PHC²2 Cavalli LO, Rizzotto MLF. Formação dos médicos que atuam como líderes das equipes de Atenção Primária em Saúde no Paraná. Rev Bras Educ Med. 2018; 42(1):29-37.^,1313 Trindade TG, Batista SR. Medicina de Família e Comunidade: agora mais do que nunca! Cienc Saude Colet. 2016; 21(9):2667-9.^,1818 Rezende VLM, Rocha BS, Naghettini AV, Pereira ERS. Análise documental do projeto pedagógico de um curso de Medicina e o ensino na Atenção Primária à Saúde. Interface (Botucatu). 2019; 23 Supl 1:e170896. doi: https://doi.org/10.1590/interface.170896.
https://doi.org/10.1590/interface.170896... , with curricula that have contributed little or directed to the choice of FCM as a specialty¹⁵15 Rodrigues LGH, Duque TB, Silva RM. Factors associated with the choice of specializing in family medicine. Rev Bras Educ Med. 2020; 44(3):e078..

Most graduates recognized FCM as a potentiality in the education of physicians for a holistic view focused on the global demands of the user, his family and the community in which he is inserted¹⁹19 Soares RS, Oliveira FP, Melo Neto AJ, Barreto DS, Carvalho ALB, Sampaio J, et al. Residência em medicina de família e comunidade: construindo redes de aprendizagens no SUS. Rev Bras Med Fam Comunidade. 2018; 13(40):1-8..

The Person-Centered Clinical Method (PCCM) is understood as key to achieve a comprehensive approach to population health problems²⁰20 Lopes JMC, Ribeiro JAR. A pessoa como centro do cuidado na prática do médico de família. Rev Bras Med Fam Comunidade. 2015; 10(34):1-13. and its application is considered imperative in the practice of family and community doctors²¹21 Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patiente-centered medicine: transforming the clinical method. 2nd ed. Abingdon: Redcliffe Medical Press; 2003.. The graduates’ perception of safety in the application of PCCM after completing the RFCM shows one of the greatest victories of this teaching strategy and of the evaluated program in particular.

Through the RFCM, graduates got to know the role of FCM, that was considered enthusing, contributing to the construction of a professional identity and identification that mark the process of residency training¹⁴14 Rodrigues EF, Forster AC, Santos LL, Ferreira JBB, Falk JW, Fabbro AL. Perfil e trajetória profissional dos egressos da residência em medicina de família e comunidade do estado de São Paulo. Rev Bras Educ Med. 2017; 41(4):604-14.. Since most medical graduates feel discouraged to work in the field²²22 Cavalcante Neto PG, Lira GV, Miranda AS. Interesse dos estudantes pela medicina de família: estado da questão e agenda de pesquisa. Rev Bras Educ Med. 2009; 33(2):198-204., these notions of engagement express a positive counterpoint in the programs studied.

The training experienced during the two years of residency provided the graduates with technical empowerment, with consequent improvement in the resolutive capacity of care and subsequent reduction of referrals to mid-level complexity, improving the care practice as a whole.

Rebolho et al.²³23 Rebolho RC, Poli Neto P, Padebôs LA, Garcia LP, Vidor AC. Médicos de família encaminham menos? Impacto da formação em MFC no percentual de encaminhamentos da Atenção Primária. Cienc Saude Colet. 2021; 26(4):1265-74. showed that FCM training through residency promoted a significant reduction in percentages of referrals from PHC, corroborating the resolutivity by professional medical qualification in primary care.

Graduates who currently work as preceptors in the RFCM highlighted that residency also prepared them for teaching through the specialization course for FCM preceptors offered by the Ministry of Health, based on the National Plan for Preceptor Training, specifically for residents who took FCM courses²⁴24 Brasil. Portaria Interministerial nº 1.618, de 30 de Setembro de 2015. Institui, no âmbito do Sistema Único de Saúde (SUS), como um dos eixos do Programa Mais Médicos - Residência, o Plano Nacional de Formação de Preceptores para os Programas de Residência na modalidade Medicina Geral de Família e Comunidade, com o fim de subsidiar e assegurar instrumentos para o processo de expansão de vagas de residência em Medicina Geral de Família e Comunidade, nos termos da Lei nº 12.871, de 22 de outubro de 2013. Diário Oficial da União. 01 Out 2015..

Encouraging preceptorship, both at undergraduate and postgraduate levels, has proven to be very effective in creating the commitment of FCM residents to their specialty, as it is a future perspective for professional growth and performance, and favors the multiplication of good practices, resulting in a better balance between care and teaching responsibilities²⁵25 Izecksohn MMV, Teixeira JE Jr, Stelet BP, Jantsch AG. Preceptoria em Medicina de Família e Comunidade: desafios e realizações em uma Atenção Primária à Saúde em construção. Cienc Saude Colet. 2017; 22(3):737-46.. The training of preceptors in FCM has been privileged in health policies, with the resident having the possibility to concomitantly join the specialization in preceptorship for their pedagogical qualification⁶6 Oliveira FP, Araújo CA, Torres OM, Figueiredo AM, Souza PA, Oliveira FA, et al. The More Doctors Program and the rearrangement of medical residency education focused on Family and Community Medicine. Interface (Botucatu). 2019; 23 Supl 1:e180008. doi: https://doi.org/10.1590/Interface.180008.
https://doi.org/10.1590/Interface.180008... .

Recognition and application of PHC attributes

Attending a RFCM course gave graduates the opportunity to learn about all PHC attributes, focusing on accessibility, comprehensiveness, longitudinality and care coordination. Thus, the application of these principles was pointed out as a fundamental circumstance for the doctor’s performance in the SUS, due to the understanding of their importance and the need to incorporate them into the healthcare practice in the health system.

PHC strengthens the health systems in which it is developed by facilitating the population’s access to a set of health actions that favor quality of life, promoting and protecting health in a global manner²⁶26 Starfield B. Is primary care essential? Lancet. 1994; 344(8930):1129-33.^,2727 Starfield B. Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gac Sanit. 2012; 26 Supl 1:20-6.. One way to measure the strengthening of PHC is by assessing its attributes and how they are applied and understood by health professionals²⁸28 Harzheim E, Oliveira MMC, Agostinho MR, Hauser L, Stein AT, Gonçalves MR, et al. Validação do instrumento de avaliação da atenção primária à saúde: PCATool-Brasil adultos. Rev Bras Med Fam Comunidade. 2013; 8(29):274-84..

The respondents pointed out that performing a job that acknowledges the attributes of PHC in services sensitized them to pay more attention to their patients and to be more resolutive in their decisions, contributing to the improvement of the quality of life of the population. This familiarization also allowed them to carry out collective and individual health promotion activities, as well as to identify the social determinants that directly influence the health-disease process in the communities.

Given that the Brazilian health context encompasses heterogeneous scenarios, the degree of adequacy of FHS services and, consequently, of its professionals to the principles of PHC enables us to measure the real effectiveness of primary care²⁷27 Starfield B. Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gac Sanit. 2012; 26 Supl 1:20-6.. Strengthening, identifying and assessing these attributes is, therefore, important work and the target of great efforts exerted by the RFCM programs²⁹29 Leão CDA, Caldeira AP. Avaliação da associação entre qualificação de médicos e enfermeiros em atenção primária em saúde e qualidade da atenção. Cienc Saude Colet. 2011; 16(11):4415-23..

Significant reports referred to the management of the clinic when referring to building the agenda according to the requirements of the territory, to the organization, to the adequate completion of medical records, to the monitoring of continued care, to risk stratification, and to the execution of care pathways.

Clinical management is guided by principles that connect health care, education and management in integrated systems, demanding a critical consciousness in the exercise of health practice³⁰30 Padilha RQ, Gomes R, Lima VV, Soeiro E, Oliveira JM, Schiesari LMC, et al. Princípios para a gestão da clínica: conectando gestão, atenção à saúde e educação na saúde. Cienc Saude Colet. 2018; 23(12):4249-57.. They go beyond the traditional universe of medical practice, whose dynamics generally involves individualistic care, focused on specific and disconnected problems, masking the real needs of patients and imposing itself as a barrier to the achievement of comprehensive care³¹31 Carnut L. Cuidado, integralidade e atenção primária: articulação essencial para refletir sobre o setor saúde no Brasil. Saude Debate. 2017; 41(115):1177-86..

There are remarkable perceptions that PHC attributes should serve as a guide for all medical specialties:

This perception emphasizes the interference of FCM training and its awareness of PHC attributes in order to transform medical practice into another specialty. FCM training would then be a way to resist to market logic, reinforced by a current agenda of restrictions and persistence of medicine with a curative and medical focus, therefore not anchored in the paradigm of health promotion³²32 Teixeira JE Jr, Romano VF, Izecksohn MMV, Faria Neto E, Paiva MBP. Interlocuções entre a Declaração de Astana, o Direito à Saúde e a formação em Medicina de Família e Comunidade no Rio de Janeiro, Brasil. Cienc Saude Colet. 2020; 25(4):1261-8..

Potentialities of FCM training

A large share of graduates stated that the RFCM contributed favorably to the development of their personal formation, making them more mature, secure, confident, autonomous and responsible. It is observed here the role of the RFCM in favoring a learning process that involves the development of attitudes and personal and professional maturing, through mentoring and role modeling, beyond technical skills and cultural dimensions that mix and overlap knowledge and perceptions³³33 Bonet O. Sentindo o saber. Educação da atenção e medicina de família. Horiz Antropol. 2015; 21(44):253-77..

The Brazilian Society of Medicine of Family and Community recognizes the importance of the implementation of interactive practices, both in undergraduate and graduate medical education, for the proper education of professionals trained to work in PHC³⁴34 Sociedade Brasileira de Medicina de Família e Comunidade (SBMFC). Desafios do ensino e da aprendizagem da Atenção Primária à Saúde e da medicina de família e comunidade na graduação e pós-graduação em medicina. In: Anais do 45o Congresso Brasileiro de Educação Médica (COBEM); 2007; Uberlândia (MG). Uberlândia: COBEM; 2007. p. 19.. This requires individuals with critical thinking, agility of thought, adaptability and recognition of territory, attitudes favored in the teaching environment that applies active methodologies, a factor clearly expressed by the graduates³⁵35 Oliveira AMF, Moreira MRC, Xavier SPL, Machado MFAS. Análise da integração ensino-serviço para a formação de residentes em medicina de família e comunidade. Rev Bras Educ Med. 2021; 45(1):e003..

The residents, inserted in the field of practice, are able to promote restructuring in services, from the implementation of new actions to the mobilization of continuing education, stimulus to preceptorship and other reciprocal movements able to improve medical training and positively impact the management of care of other professionals working in the same context³⁵35 Oliveira AMF, Moreira MRC, Xavier SPL, Machado MFAS. Análise da integração ensino-serviço para a formação de residentes em medicina de família e comunidade. Rev Bras Educ Med. 2021; 45(1):e003..

The relevance of the doctor-patient relationship was consistently pointed out, with the establishment of a bond and trust between the professional and the community, providing greater ownership and resoluteness in care. Therefore, it was argued by the graduates that the doctor-patient relationship is developed at all moments of care, from the reception to the adoption of conducts that prioritize the health and well-being of the patient.

The transversality of the doctor-patient relationship is the foundation for the evaluation and progression of communication skills in medical practice³⁶36 Padilla EM, Sarmiento-Medina P, Ramirez-Jaramillo A. Percepciones de pacientes y familiares sobre la comunicación con los profesionales de la salud. Rev Salud Publica. 2014; 16(4):585-96.. By assimilating and assuming the understanding of the other, the physician gets closer to the patient, resorting to the various sources of explanation and understanding of the problems and using individualized strategies adapted to the most diverse contexts of health care³⁷37 Caprara A, Franco ALS. A relação paciente-médico: para uma humanização da prática médica. Cad Saude Publica. 1999; 15(3):647-54..

The graduates also mentioned that the active methodologies and communication techniques employed in the RFCM curriculum positively supported their empowerment for care practice, as they felt qualified to face PHC challenges, due to the proximity with patients and the constant search for knowledge to meet users’ expectations:

This perception illustrates how active methodologies acquire their own profile in training to work in health, given the interdependence between theory and practice, coupled with the development of a comprehensive perception of people and the expansion of the concept of care, all needed for the adequacy of the attitudes of health professionals to the context of people’s health needs³⁸38 Paiva MRF, Parente JRF, Brandão IR, Queiroz AHB. Metodologias ativas de ensino-aprendizagem: revisão integrativa. Sanare (Sobral). 2016; 15(2):145-53.^,3939 Mitre SM, Siqueira-Batista R, Girardi-de-Mendonça JM, Morais-Pinto NM, Meirelles CAB, Pinto-Porto C, et al. Metodologias ativas de ensino-aprendizagem na formação profissional em saúde: debates atuais. Cienc Saude Colet. 2008; 13 Supl 2:2133-44..

Graduates working in another specialty pointed out several contributions of RFCM in their work process, even if in another field. One of them is linked to the possibility of coming into contact with other specialties during rotations in the specialty ambulatories. This socialization with other areas helped them to better perceive their professional affinities.

This context may suggest that, during the rotation in focal specialties, the young doctors have the opportunity to verify several aspects of these specialties, which can interfere in their choice at the end of the RFCM program. Opting for another area goes through aspects related to patient perception that focal specialists are more qualified, by the attractive financial possibility of the private market, by the supposed status and even by the identification of a profile for another specialty⁴⁰40 Martins JB, Rodriguez FP, Coelho ICMM, Silva EM. Fatores que influenciam a escolha da especialização médica pelos estudantes de medicina em uma instituição de ensino de Curitiba (PR). Rev Bras Educ Med. 2019; 43(2):152-8..

However, the graduates believe that having done residency was important even for their work outside PHC. They noticed that the patients themselves refer that they have a differentiated care regarding other specialists.

This difference points FCM as a priority specialty to train professionals to care for people in different moments and life cycles, by developing competences centered on a biopsychosocial rationality perspective. Thus, FCM training has contributed to form more welcoming and humanized professionals for and beyond PHC⁸8 Anderson MIP, Rodrigues RD. Formação de especialistas em Medicina de Família e Comunidade no Brasil: dilemas e perspectivas. Rev Bras Med Fam Comunidade. 2011; 6(18):19-20..

Challenges of the specialty

The most noticeable difficulty in the respondents’ explanations concerns the lack of professional valorization in FCM, either by colleagues from other areas, or by the non-recognition of the importance of the specialty by the management of public health services, even the devaluation shown by patients - users of the health system.

There are complex variables that may influence the choice of a medical career and seem to be more implicated in personal and professional factors related to the specialty and residency program chosen than to academic issues, also going through ideological aspects¹⁵15 Rodrigues LGH, Duque TB, Silva RM. Factors associated with the choice of specializing in family medicine. Rev Bras Educ Med. 2020; 44(3):e078.^,4141 Raghavendran S, Inbaraj LR. Do family physicians suffer an identity crisis? A perspective of family physicians in Bangalore city. J Family Med Prim Care. 2018; 7(6):1274-8.. From the young professional’s perspective, the focal specialties represent the opportunity for social ascension and, in the medical field, both in financial terms and prestige⁴⁰40 Martins JB, Rodriguez FP, Coelho ICMM, Silva EM. Fatores que influenciam a escolha da especialização médica pelos estudantes de medicina em uma instituição de ensino de Curitiba (PR). Rev Bras Educ Med. 2019; 43(2):152-8.. This justifies a feeling of dissatisfaction, also presented by graduates at the moment of entering the job market, when facing low salaries due to the lack of salary incentive by the local management when contacting a professional to work in PHC with the FCM specialty.

The efforts to make FCM an attractive field for future professionals encompass several variables, but the search for better salaries and status are remarked in the decision process of postgraduate work, representing an obstacle for professionals to be attracted and remain in the area in larger numbers⁴²42 Mello GA, Mattos ATR, Souto BGA, Fontanella BJB, Demarzo MMP. Médico de família: ser ou não ser? Dilemas envolvidos na escolha desta carreira. Rev Bras Educ Med. 2009; 33(3):464-71.^,4343 Kost A, Bentley A, Phillips J, Kelly C, Prunuske J, Morley CP. Graduating medical student perspectives on factors influencing specialty choice an AAFP national survey. Fam Med. 2019; 51(2):129-36.. However, this reality has been changing in recent decades, with inductive policies for the universalization and prioritization of FCM, several competitive examinations for FCM with satisfactory remuneration and incentives for graduates of RFCM to score points for entry into other residency programs⁶6 Oliveira FP, Araújo CA, Torres OM, Figueiredo AM, Souza PA, Oliveira FA, et al. The More Doctors Program and the rearrangement of medical residency education focused on Family and Community Medicine. Interface (Botucatu). 2019; 23 Supl 1:e180008. doi: https://doi.org/10.1590/Interface.180008.
https://doi.org/10.1590/Interface.180008... .

Political interference by management was reported by graduates, which directly reflects on the residency program activities, since the main fields of work for FCM residents and specialists are the municipality’s Family Health Strategy (FHS) units.

The need for management to prioritize PHC with responsible investment in the structure and organization of services is pointed out as a source of dissatisfaction on the part of PHC professionals, standing in the way of universal and equitable access to PHC⁴⁴44 Lima SAV, Silva MRF, Carvalho EMF, Pessoa EAC, Brito ESV, Braga JPR. Elementos que influenciam o acesso à atenção primária na perspectiva dos profissionais e dos usuários de uma rede de serviços de saúde do Recife. Physis. 2015; 25(2):635-56.. Only part of the managers identify the potential of the RFCM for the improvement of the service and even so, it does not mean that they will use this potential in political practices, not using the medical residency as a propeller factor of PHC⁷7 Leite APT, Correia IB, Chueiri PS, Sarti TD, Jantsch AG, Waquil AP, et al. Residência em Medicina de Família e Comunidade para a formação de recursos humanos: o que pensam gestores municipais? Cienc Saude Colet. 2021; 26(6):2119-30..

However, the RFCM in Palmas-TO have been prioritized by the local municipal management, which recognizes training as the differential capable of mobilizing professionals and transforming them, as they themselves report. The residents thus occupy an important role for the development of the municipal PHC, whose management has understood the RMFC program as a possibility of intervention that leads to a significant virtuous circle⁷7 Leite APT, Correia IB, Chueiri PS, Sarti TD, Jantsch AG, Waquil AP, et al. Residência em Medicina de Família e Comunidade para a formação de recursos humanos: o que pensam gestores municipais? Cienc Saude Colet. 2021; 26(6):2119-30..

The work overload during training emerged in the answers of a few graduates. It was noticed that the broad spectrum of activities of the specialty together with the frequent demands of the management technical areas sometimes makes the residency tiring and residents feel overloaded.

This overload can be related to the characteristics of this residency, particularly its wide scope of action, the frequent diagnostic uncertainty, the emotional demands of the relationship with users and community, and the fast need to acquire autonomy⁴⁵45 Santos SCR, Viegas AIF, Morgado CIMO, Ramos CSV, Soares CND, Roxo HMCJ, et al. Prevalência de burnout em médicos residentes de Medicina Geral e familiar em Portugal. Rev Bras Med Fam Comunidade. 2017; 12(39):1-9..

Reflections on the pedagogical activities of these programs and the possible impact of this training on medical practice and population health were evidenced, and may also guide the decision-making process of managers in the context of public health policies, with emphasis on teaching-service integration of RFCM.

Final considerations

Some limitations of the study may be linked to the possible loss of communication and interaction for the detection of emotions and deepening typical of in-depth interviews. Still, owing to the adherence of all graduates, the results demonstrated the relevance of the RFCM in the training of professionals able to perform the attributes of the Brazilian PHC and the need for increasing appreciation of public policies that support and expand this training.

The fact that most of the graduates from the Palmas-TO RFCM are still working in the specialty after completing residency confirmed their perception, as well as that of graduates working in other areas, about the significant contributions of this training in influencing the current work process, in and beyond PHC, guided by their respective essential attributes.

The RFCM has shown to have a strategic potential to promote and retain professionals, especially in the region under study, contributing to the qualification and resolutivity of the local PHC. Through active methodologies integrated to services, graduates realize that FCM training provides advances in humanized professional practice, bringing tension to the restructuring of services, management and interpersonal relationships in health care, a transformation that goes beyond the professional to the personal dimension.

In spite of the challenges linked to the social devaluation of FCM, low remuneration, political influence in management and difficulties of professional establishment in the specialty, the findings ratify that RFCM has provided increasing recognition and identification with the specialty, improvement of medical practice and the expansion of integral care for restructuring the PHC care model, when properly prioritized and structured by management and training institutions.

Acknowledgments

To the Fundação Escola de Saúde Pública of Palmas-TO.

To the Graduate Program in Family Health of the Federal University of Paraíba, Health Sciences Center.

To the Northeast Network for Training in Family Health (RENASF).

References

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