Como moldar o modelo de ensino no contexto da administração hospitalar após a implantação do Sistema Único de Saúde? / How to shape the teaching model in the context of hospital administration after the implementation of the Unified Health System?

O ensino médico e os programas de residência médica no Brasil sofreram grandes mudanças após a implantação do Sistema Único de Saúde (SUS). Historicamente, eles eram programados para serem desenvolvidos quase que exclusivamente dentro de um hospital-escola ligado à sua universidade de origem. Os hospitais universitários (HUs) até então eram completamente desvinculados do sistema público de saúde e cada um estabelecia as suas regras de funcionamento. Seus pacientes mesclavam-se entre os de alta, média e baixa complexidade, de acordo com uma agenda regulada pelos departamentos clínicos e a administração do hospital. O SUS deu lugar a uma descentralização da assistência, com regulação hierarquizada do fluxo de pacientes e muita ênfase na promoção da saúde, prevenção de doenças e atenção primária, com foco importante nos Programas de Saúde da Família (PSF). Por conta da hierarquização da assistência no SUS, os pacientes de menor grau de complexidade passaram a ficar "retidos" na rede assistencial de nível primário e secundário, e os HUs públicos, por força da lei, passaram a fazer parte integrante do sistema público de saúde como referência para pacientes em nível terciário de complexidade. Os gestores dos HUs viram-se diante de um dilema: como ensinar Medicina para a graduação e residência médica se os pacientes de níveis primário e secundário de complexidade passaram a não mais fazer parte da clientela desses hospitais?

[Feedback on the first three years of application of the reform of the third cycle in oncology]. / La phase socle en oncologie : retour d'expérience sur les trois premières années d'application de la réforme du troisième cycle.

Since the establishment of the reform of medical studies' third cycle in 2017, the first two residency semesters define the "phase socle" whose objective is to provide the basic knowledge of the specialty. We have carried out a declarative survey, submitted in 2020 to all French residents in Oncology whose "phase socle" had taken place during the first 3 years of the reform. The main objectives of this survey were to evaluate the theoretical teaching of oncology as well as the practical hospital training provided during this phase. The response rate was 44% (among 355 residents, 155 answered). In terms of theoretical training, the level of satisfaction with the national teaching courses of the Collège National des Enseignants en Cancérologie and the distant learning courses on the SIDES-NG platform was considered satisfactory (average visual analog scale of 6.7/10 and 5.7/10, respectively). There was greater heterogeneity in the organization of local courses, of which only 50% of base phase residents benefited. In terms of practical training, the training value of the medical oncology and radiation oncology residencies was good (visual analogue scale 7.9/10 and 6.7/10, respectively), with educational objectives adapted to the base phase, but with a greater workload for medical oncology. This study provides feedback that shows the success of this reform in oncology. It also offers suggestions, which could be the basis to improve the formation of oncology residents.

Diversity Is Not Enough: Advancing a Framework for Antiracism in Medical Education.

Medical students, residents, and faculty have begun to examine and grapple with the legacy and persistence of structural racism in academic medicine in the United States. Until recently, the discourse and solutions have largely focused on augmenting diversity across the medical education continuum through increased numbers of learners from groups underrepresented in medicine (UIM). Despite deliberate measures implemented by medical schools, residency programs, academic institutions, and national organizations, meaningful growth in diversity has not been attained. To the contrary, the UIM representation among medical trainees has declined or remained below the representation in the general population. Inequities continue to be observed in multiple domains of medical education, including grading, admission to honor societies, and extracurricular obligations. These inequities, alongside learners' experiences and calls for action, led the authors to conclude that augmenting diversity is necessary but insufficient to achieve equity in the learning environment. In this article, the authors advance a 4-step framework, built on established principles and practices of antiracism, to dismantle structural racism in medical education. They ground each step of the framework in the concepts and skills familiar to medical educators. By drawing parallels with clinical reasoning, medical error, continuous quality improvement, the growth mindset, and adaptive expertise, the authors show how learners, faculty, and academic leaders can implement the framework's 4 steps-see, name, understand, and act-to shift the paradigm from a goal of diversity to a stance of antiracism in medical education.

Characteristics and Attitudes of Aspiring Cardiothoracic Surgeons: A Survey Study.

BACKGROUND: Although recruiting highly qualified, diverse applicants into cardiothoracic surgery remains a national priority, their characteristics remain unknown. This study aims to describe current and future applicants in cardiothoracic surgery. METHODS: Aspiring cardiothoracic surgeons (students interested in matriculating in a North American training program) were voluntarily enrolled in the study through Twitter and email outreach. A 33-question survey evaluated their backgrounds, research experiences, attitudes, and interests within cardiothoracic surgery. Standard descriptive statistics were used. RESULTS: There were 111 participants, 40 of whom were female (36.0%) and 27 of whom identified as an underrepresented minority (24.3%). Of the total, 63 belonged to an institution with a cardiothoracic surgery training program (56.8%). A total of 91 students envisioned having a mostly operative career (82.0%) and 75 envisioned pursuing educational roles (67.6%). The most popular surgical specialties were heart transplantation (50.5%) and aortic surgery (47.8%). Participants selected having a high-intensity operative environment (81.2%) and an innovative academic environment (58.8%) as the most attractive qualities. Perceived lack of work-life balance (46%) and toxic training or work environment (28%) were the greatest deterrents. Finances during the application process were perceived as a potential barrier by 41 students (36.9%). Approximately 75% of students (83 of 111) had faculty as mentors; 46.8% (56 of 111) thought that cardiothoracic surgery faculty were approachable but had limited time for mentorship. CONCLUSIONS: This survey study characterized a nationally selected pool of aspiring cardiothoracic surgeons using social media. Future studies involving larger and more diverse cohorts are warranted to find areas for improvement in recruitment, retention, and diversity.

[Application of the « Junior Doctor ¼ status in Radiation Oncology]. / Guide du Docteur Junior en oncologie-radiothérapie.

Introduced in 2017, the reform of the 3rd cycle has modified the organization of the residency in all specialties, and in particular radiation oncology. The residency was thus divided into 3 phases with increasing knowledge and responsibilities. The latter, carried out under the status of "junior doctor", created and defined by decree n°2018-571 of July 3, 2018 and the decree of January 16, 2020, is a phase of supervised autonomy of the resident. Radiotherapy is a singular specialty, with multiple and complex activities, and requires multiple skills. A guide defining the status of the "Junior Doctor" in radiation oncology therefore appears necessary, defining each resident's role and obligations. This guide is of an advisory nature and must be adapted to the particularities of each department. This guide aims to help the implementation of the reform of the 3rd cycle in radiation oncology and especially the final year called the consolidation phase. It is destined to evolve, expanded by individual and collective feedback and the constant renewal of our speciality.

Historical Trajectory and Implications of Duty-Hours in Graduate Medical Education.

Duty-hours policies continue to be debated. Most know the pro and con arguments, but many may not be aware of background information preceding and intertwining the development and implementation of these policies. Interestingly, several aspects of law were involved or potentially correlated with policies enacted. This review updates new generations of physicians and scholars on the historical trajectory of duty-hour policies and highlights policy implications and the current state of evidence. In reviewing the historical and legal trajectory of duty-hours, many updates seemed to be a reaction to potential federal entanglement. Additionally, the review of the postimplementation literature revealed minimal empirical evidence. Instead, the majority of the positive findings were perception based. These summaries demonstrate a need for further outcomes evidence to validate policies.

Trends in Accreditation Council for Graduate Medical Education Accreditation for Subspecialty Fellowship Training in Plastic Surgery.

BACKGROUND: The purposes of this study were to (1) determine the proportion of plastic surgery residents pursuing subspecialty training relative to other surgical specialties, and (2) analyze trends in Accreditation Council for Graduate Medical Education accreditation of plastic surgery subspecialty fellowship programs. METHODS: The American Medical Association provided data on career intentions of surgical chief residents graduating from 2014 to 2016. The percentage of residents pursuing fellowship training was compared by specialty. Trends in the proportion of accredited fellowship programs in craniofacial surgery, hand surgery, and microsurgery were analyzed. The percentage of accredited programs was compared between subspecialties with added-certification options (hand surgery) and subspecialties without added-certification options (craniofacial surgery and microsurgery). RESULTS: Most integrated and independent plastic surgery residents pursued fellowship training (61.8 percent versus 49.6 percent; p = 0.014). Differences existed by specialty from a high in orthopedic surgery (90.8 percent) to a low in colon and rectal surgery (3.2 percent). From 2005 to 2015, the percentage of accredited craniofacial fellowship programs increased, but was not significant (from 27.8 percent to 33.3 percent; p = 0.386). For hand surgery, the proportion of accredited programs that were plastic surgery (p = 0.755) and orthopedic surgery (p = 0.253) was stable, whereas general surgery decreased (p = 0.010). Subspecialty areas with added-certification options had more accredited fellowships than those without (100 percent versus 19.2 percent; p < 0.001). CONCLUSION: There has been slow adoption of accreditation among plastic surgery subspecialty fellowships, but added-certification options appear to be highly correlated.

Insta-grated Plastic Surgery Residencies: The Rise of Social Media Use by Trainees and Responsible Guidelines for Use.

BACKGROUND: Ethical guidelines for appropriate use of social media are beginning to be delineated. As social media becomes ingrained in plastic surgery culture, education of residents on appropriate use of social media is increasingly important. Recently, plastic surgery residency programs have begun to utilize social media. OBJECTIVES: This study characterized the trends and content of plastic surgery residency-associated Instagram accounts. METHODS: Active individual residency program Instagram accounts were identified for integrated plastic surgery programs. Metrics for each account were retrieved on September 16, 2017, including date of first post, number of posts, and followers. Individual posts were analyzed for content of post. RESULTS: Fourteen of 67 (21%) integrated plastic surgery programs were found to have active Instagram accounts. There has been an exponential growth of programs adopting Instagram since August 2015. A total of 806 posts were created. Thirty-two (3.97%) posts had intraoperative photos and only one (0.12%) showed a patient image. There were 4466 followers of plastic surgery residency programs. A linear correlation was found between number of posts and number of followers, while there was no correlation of number of followers and time since account start. CONCLUSIONS: Instagram use by plastic surgery integrated programs continues to grow exponentially, and programs are appropriately using the platform. Active use of the resident social media results in increased influence. Resident use of social media has many benefits. We propose social media guidelines for plastic surgery trainees and advocate for continued appropriate use and autoregulation by plastic surgery trainees.

Manual do programa de residência médica da Secretaria de Estado da saúde - SES / Manual of the medical residency program of the State Department of Health - SES

O presente Manual da Residência Médica tem por objetivo orientar, esclarecer dúvidas e apresentar as Normas e Rotinas que devem ser obedecidas pelos médicos residentes que ingressam nas instituições, oriundos do Processo Seletivo de Residência Médica da SES.

Experience of plastic surgery registrars in a European Working Time Directive compliant rota.

BACKGROUND: Surgical training requires exposure to clinical decision-making and operative experience in a supervised environment. It is recognised that learning ability is compromised when fatigued. The European Working Time Directive requires a decrease in working hours, but compliance reduces trainees' clinical exposure, which has profound implications for plastic surgery training. The aim of this study was to evaluate plastic surgery registrars' experience of an EWTD-compliant rota, and to examine its impact on patient care, education, and logbook activity. METHODS: An electronic survey was distributed to plastic surgery registrars in a university teaching hospital. Registrars were asked to rate 31 items on a five-point Likert scale, including statements on patient care, clinical and operative duties, training, and quality-of-life. Interquartile deviations explored consensus among responses. Operative caseload was objectively evaluated using eLogbook data to compare activity at equal time points before and after implementation of the EWTD rota. RESULTS: Highest levels of consensus among respondents were found in positive statements addressing alertness and preparation for theatre, as well as time to read and study for exams. Registrars agreed that EWTD compliance improved their quality-of-life. However, it was felt that continuity of patient care was compromised by work hours restriction. Registrars were concerned about their operative experience. eLogbook data confirmed a fall-off in mean caseload of 31.8% compared to activity prior to EWTD rota implementation. CONCLUSION: While EWTD compliant rotas promote trainee quality-of-life and satisfaction with training, attention needs to be paid to optimising operative opportunities.