A retomada do Programa Mais Médicos em 2023 / La reanudación del Programa Mais Médicos en 2023 / The resumption of the Mais Médicos Program in 2023

RESUMO: Os vazios assistenciais e a demanda por médicos no Sistema Único de Saúde são problemas crônicos, principalmente nas regiões mais vulneráveis do Norte e Nordeste e em áreas periféricas de centros urbanos. Frente a essa necessidade, o governo federal está recompondo o Programa Mais Médicos para o Brasil, por meio dos ministérios da Saúde, da Educação e da Fazenda. Os principais eixos do programa são a provisão de médicos na Atenção Primária em Saúde e a formação desses profissionais, nessa versão associados à especialização e mestrado profissional, tendo como referência a concepção de Atenção Primária à Saúde integral. Nesta nota de conjuntura, trazemos informações sobre a trajetória oficial deste movimento de retomada, recuperando brevemente características e avanços proporcionados por essa política - instituída primeiramente em 2013 - e apresentando peculiaridades da versão atual, proposta pewla medida provisória n. 1.165, de 20 de março de 2023, convertida em lei (n. 14.621/2023) e sancionada em julho deste ano.

RESUMEN: Las brechas de asistencia y la demanda de médicos en el Sistema Único de Salud son problemas crónicos, especialmente en las regiones más vulnerables del Norte y del Noreste y en las zonas periféricas de los centros urbanos. Ante esta necesidad, el gobierno federal está recomponiendo el Programa Mais Médicos para Brasil, a través de los ministerios de Salud, Educación y Hacienda. Los principales ejes del programa son la provisión de médicos en Atención Primaria de Salud y la formación de estos profesionales, en esta versión asociada a la especialización y maestría profesional, con referencia al concepto de atención primaria para la salud integral. En esta nota de coyuntura, traemos información sobre la trayectoria oficial de este movimiento de reanudación, recuperando brevemente las características y los avances proporcionados por esta política - establecida por primera vez en 2013 - y presentando las peculiaridades de la versión actual, propuesta por la medida provisional n. 1.165, del 20 de marzo de 2023, convertida en ley (n. 14.621/2023) y sancionado en julio de este año.

ABSTRACT: Healthcare gaps and the demand for physicians in the Brazilian Health System are chronic problems, especially in the most vulnerable regions of the North and Northeast and in peripheral areas of urban centers. In view of this need, the federal government is recomposing the Mais Médicos Program for Brazil, through the ministries of Health, Education and Finance. The main axes of the program are the provision of doctors in Primary Health Care and the training of these professionals, in this version associated with specialization and professional master's, with reference to the concept of primary care for integral health. In this note of conjuncture, we bring information about the official trajectory of this recovery movement, briefly recovering characteristics and advances provided by this policy - first established in 2013 - and presenting peculiarities of the current version, proposed by provisional measure n. 1.165, of March 20th, 2023, converted into law (n. 14.621/2023) and sanctioned in July of this year.

Conocimiento sobre cuidados paliativos pediátricos de los pediatras de atención primaria del Principado de Asturias, España / Knowledge of primary care pediatricians about pediatric palliative care in the Principality of Asturias, Spain

Resumen Introducción: Es importante conocer y evaluar la experiencia y el conocimiento de los pediatras de atención primaria del Principado de Asturias (España) sobre los cuidados paliativos pediátricos. Métodos: Se llevó a cabo un estudio descriptivo y transversal mediante un cuestionario dirigido a los pediatras de atención primaria del Principado de Asturias entre mayo y junio de 2018. Resultados: El 77% de los participantes no poseía formación previa y el 100% consideró que sus conocimientos en cuanto al tema no eran adecuados, a pesar de que el 37% había atendido en alguna ocasión a pacientes subsidiarios de este tipo de cuidados. Casi la totalidad de los encuestados (97%) consideraron necesaria la creación de una unidad de cuidados paliativos pediátricos. Conclusiones: El conocimiento del pediatra de atención primaria del Principado de Asturias con respecto a los cuidados paliativos pediátricos es muy escaso en una región en la que no se dispone de una unidad pediátrica exclusiva. Sería interesante aprovechar la gran disposición de este grupo de profesionales para mejorar su formación, además de incorporar la materia en facultades y en la formación del médico interno residente.

Abstract Background: To know and assess the experience and knowledge among primary care pediatricians about pediatric palliative care in the Principality of Asturias (Spain). Methods: A descriptive and cross-sectional analysis was conducted using a survey among primary care pediatricians in the Principality of Asturias between May and June 2018. Results: The majority of participants (77%) did not receive previous training, and 100% considered that their knowledge on the subject was insufficient, although 37% had occasionally attended to palliative care patients. Almost all participants (97%) considered that a pediatric palliative care unit is necessary. Conclusions: The knowledge of primary care pediatricians about pediatric palliative care is deficient in the Principality of Asturias, a region where no exclusive pediatric unit exists. It would be interesting to seize the opportunity to improve the training of these pediatricians, given their great willingness, and to incorporating the subject into colleges and medical intern formation as well.

Necesidades de aprendizaje de médicos de atención primaria sobre reperfusión coronaria en el infarto agudo del miocardio / Learning necessities of primary care doctors on coronary reperfusion in the acute myocardial infarction

Introducción: el conocimiento sobre reperfusión coronaria en el infarto agudo del miocardio con elevación del segmento ST en el nivel primario de atención es de extraordinaria importancia para disminuir las complicaciones y la mortalidad. Objetivo: determinar las necesidades de aprendizaje de médicos de atención primaria sobre reperfusión coronaria en el infarto agudo del miocardio. Método: se realizó un estudio descriptivo de 65 galenos que laboraban en 5 policlínicos principales de urgencias de Santiago de Cuba en noviembre del 2017, para lo cual se aplicó una encuesta con variables de interés, que se calificó según metodología de evaluación y estándar previamente establecida por el equipo de trabajo. Resultados: del total de preguntas, solo una (5,9 por ciento) cumplió con el estándar de más de 70 por ciento de médicos con respuestas adecuadas; los años de experiencia y haber recibido adiestramiento influyeron positivamente en el número de dichas respuestas. La falta de capacitación fue la causa por la cual no se aplicó el tratamiento, y la planificación de esta, así como la creación de algoritmos de trabajo resultaron las medidas más propuestas por los galenos. Ninguno de ellos refirió sentirse adiestrado correctamente. Conclusiones: los médicos que laboraban en los 5 policlínicos principales de urgencias mostraron necesidades de aprendizaje y capacitación sobre el proceso de reperfusión coronaria.

Introduction: the knowledge on coronary reperfusion in the acute myocardial infarction with elevation of the ST segment in the primary care level is of extraordinary importance to decrease complications and mortality. Objective: to determine the necessities of doctors from primary care on coronary reperfusion in the acute myocardial infarction. Method: a descriptive study of 65 physicians who worked in 5 main polyclinics for emergencies of Santiago de Cuba was carried out in November, 2017 for which a survey with variables of interest was applied which was qualified according to evaluation methodology and previously established standard by the working team. Results: of all questions, only one (5.9 percent) fulfilled the standard of more than 70 percent of doctors with appropriate responses; the years of experience and receiving a previous training influenced positively in the number of these responses. The lack of training was the cause for which the treatment was not applied, and its planning, as well as the creation of working algorithms were the measures mostly proposed by the physicians. None of them referred to be correctly trained. Conclusions: doctors who worked in the 5 main emergency polyclinics showed learning necessities and training on the management for coronary reperfusion.

Aspectos de interés sobre dermatitis atópica, su diagnóstico y tratamiento / Interest aspects about Atopic Dermatitis, its diagnosis and treatment

RESUMEN La evolución favorable de los pacientes afectados con dermatitis atópica está muy relacionada con un diagnóstico y orientación precoz en la atención primaria, para un seguimiento más especializado en las consultas de dermatología y alergología, por ser una entidad que ofrece dificultades en su identificación. Es necesario incrementar el nivel de información en los médicos de las áreas de salud, por ser estos escenarios donde ocurre el primer contacto con el paciente. El objetivo es ofrecer una visión actualizada sobre el diagnóstico y tratamiento de la dermatitis atópica que contribuya a la formación de los médicos en la atención primaria. Se realiza una revisión bibliográfica de los últimos 5 años, principalmente en las bases de datos PubMed y Scielo sobre el tema. Se abordan aspectos de interés relacionados con las manifestaciones clínicas, criterios diagnósticos y tratamiento. Los resultados que se ofrecen en este trabajo contribuirán a la formación profesional para una mejor promoción, prevención, diagnóstico precoz y tratamiento de esta enfermedad, cuya prevalencia es mayor en la infancia.

ABSTRACT The favorable evolution of the patients affected with Atopic Dermatitis is quite related with a diagnosis and precocious orientation in the primary attention, for a more specialized follow up in the dermatology and alergology consultations, as it is an entity that offers difficulties in its identification. It is necessary to increase the level of knowledge of doctors in these medical areas as these are the scenarios where it occurs the first contact patient doctor. Offering an updated vision about Atopic Dermatitis that contributes to the continuous formation of the professionals of the health sector in the primary attention. A revision of articles in the PubMed and Scielo database is carried out principally during the last 5 years. Aspects of interest related with the clinical manifestations, diagnoses criteria and treatment are considered. The results that are offered in this work will contribute to the professional formation for a better promotion, prevention, precocious diagnosis and treatment of this illness that is more likely to be found in the childhood.

Necesidades de aprendizaje del especialista de Medicina General Integral sobre la conducta violenta / The family medicine specialists' learning needs about violent behavior

Introducción: las necesidades de aprendizaje resultan de contrastar un desempeño ideal o propuesto con el real, bien sea para un individuo o un grupo determinado. Constituyen el punto de partida para la búsqueda de una solución pedagógica, a fin de contribuir a la transformación cualitativa de los servicios de salud, y su oportuna identificación una trascendental herramienta de la educación permanente. Objetivo : identificar las necesidades de aprendizaje de los médicos que laboran en los Equipos de Atención Primaria de Salud, del municipio Playa, sobre la conducta violenta. Métodos: como método empírico se aplicó un cuestionario con carácter anónimo, en forma de examen escrito, a 22 especialistas de Medicina General Integral, seleccionados al azar, que laboran en tres policlínicas del extremo Este, del municipio Playa. Resultados: se puntualizaron las deficiencias e insuficiencias de los conocimientos y habilidades profesionales sobre el fenómeno de la violencia, fundamental, en lo que respecta a su dimensión cognitiva y su manifestación en niños, mujeres y ancianos. Conclusiones: a pesar de que el fenómeno de la violencia constituye, en el primer nivel de atención, uno de los Programas priorizados, en lo que a Salud Mental se refiere, la mayoría de los especialistas no lo identifican como es debido, por lo que persiste como un comportamiento infradiagnosticado, cuyo riesgo es, en lo habitual, poco explorado y su evaluación adolece, en ocasiones, de elementos de obligatoria indagación y conocimiento, lo que afecta su calidad y su adecuado seguimiento(AU)

Introduction: The learning needs result from contrasting an ideal or proposed performance with the real, either for an individual or a particular group. They constitute the starting point for seeking a pedagogical solution, in order to contribute to the qualitative transformation of health services, and their timely identification constitutes a transcendental tool of lifelong education. Objective: To identify the needs of learning on violent behavior of the physicians who work in the primary health care teams of Playa Municipality. Methods: As an empirical method, a questionnaire was conducted, with an anonymously character and as a written examination, on 22 family medicine specialists randomly chosen and who work in three polyclinics of the East end of Playa municipality. Results: The deficiencies and inadequacies of professional knowledge and skills on the phenomenon of violence were pointed out, fundamentally with regard to their cognitive dimension and their manifestation in children, women and the elderly. Conclusions: Although the phenomenon of violence constitutes, in primary health care, one of the priority programs, as far as it is about mental health, most specialists do not identify it correctly. It persists as an underdiagnosed behavior, whose risk is sometimes scarcely explored and its evaluation often suffers from elements of obligatory inquiry and knowledge, which affects its quality and its adequate update(AU)

Impacto de una capacitación en trastornos depresivos para médicos generales de atención primaria en salud: Resultados cualitativos / Qualitative impact of a training program on depressive disorders for primary care physicians

Background: There are suggestions that, despite training efforts for Primary Health Care physicians, difficulties in making accurate diagnoses and timely treatments persist. Aim: To evaluate the impact of a new training model in Depressive disorders integrated with Mindful Practice, on the diagnostic and therapeutic skills of primary care general physicians. Material and Methods: A voluntary sample of 56 general physicians was studied. The design of this study was experimental and randomized, with two groups attending theoretical sessions followed by differing workshops that were carried out in a parallel fashion. The Quantitative phase of this study considered measuring the impact of training in physician s skills. The Qualitative phase included nine semi-structured interviews and Qualitative Content Analysis. This paper reports the results of the interviews. Results: As a consequence of training sessions, physicians learned that above the mental health problems, other issues such as self-efficacy and self-confidence are important for the management of depressive patients. Conclusions: This qualitative study shows that physicians are obtaining significant benefits from their training sessions.

Barreras de acceso a tratamiento de la depresión posparto en Centros de Atención Primaria de la Región Metropolitana: un estudio cualitativo / Barriers restricting postpartum depression treatment in Chile

Background: In Chile, postpartum depression is a prevalent and disabling condition. Universal screening is available but has not been translated into better treatment rates, suggesting the existence of access barriers. Aim: To describe access barriers to postpartum depression treatment in six primary health care clinics in Metropolitan Santiago, Chile. Material and Methods: Twenty women with postpartum depression and 18 primary health care professionals were subjected to a semi-structured interview. A qualitative methodology based on Grounded Theory was used. Results: There are user associated barriers such as lack of knowledge about the disease, a negative conceptualization and rejection of available treatment options. There are also barriers associated with poor network support and some features of the health care system such as long waiting times and lack of coordination between clinical and administrative decisions. Conclusions: Patient and provider related barriers restricting treatment of postpartum depression were identified.

Factors related to the performance of Specialized Dental Care Centers / Fatores relacionados ao desempenho de Centros de Especialidades Odontológicas

The Specialized Dental Care Centers (SDCC) have the mission to expand access to public medium complexity dental care and support the primary health care actions at this level of complexity. However, it is necessary to ensure the quality of services and to evaluate such services continuously to identify weaknesses and strengths that support the processes of leadership/management. Nevertheless, there is a dearth of studies on the assessment of oral health in specialized care that may indicate which factors should be investigated. Therefore, this integrated literature review sought to explore the plethora of publications on the evaluation of SDCC in the LILACS and MEDLINE data bases in October 2013 to identify factors possibly related to the performance of such health services. Thus, 13 references were included in this review pointing to forms of organization and management of work processes related to the creation of healthcare networks (operation of regulation centers and setting up of health consortiums). They include the contextual characteristics of the places where SDCCs are located (population size, Family Health Strategy coverage, Municipal Human Development Index, governance, governing capacity) were factors that influenced the SDCCs performance.

Os Centros de Especialidades Odontológicas (CEO) têm a missão de ampliar o acesso à assistência pública odontológica de média complexidade e apoiar as ações da atenção primária neste nível. Porém, é preciso garantir a qualidade dos serviços, sendo mister avaliá-los continuamente, para identificar fragilidades e potencialidades que subsidiem os processos de gerência/gestão. Mas, há uma escassez de estudos avaliativos em saúde bucal na atenção especializada que possam indicar os fatores a serem investigados. Por isto, esta revisão integrativa de literatura objetivou explorar o panorama de publicações acerca de avaliação de CEO nas bases Lilacs e MedLine, em Outubro de 2013, e identificar os fatores possivelmente relacionados ao desempenho desses centros. Assim, foram incluídas nesta revisão 13 referências, apontando as formas de organização e gerenciamento dos processos de trabalho congruentes à construção das Redes de Atenção à Saúde (implantação de centros de regulação e formação de consórcios de saúde), bem como as características contextuais dos locais onde os CEO estão situados (porte populacional, cobertura de estratégia saúde da família, índice de desenvolvimento humano, governabilidade, capacidade de governo), como fatores relacionados ao desempenho.

Federalism, the Economic-Industrial Health Care Complex and High-Cost Pharmaceutical Assistance in Brazil / Federalismo, complexo econômico-industrial da saúde e assistência farmacêutica de alto custo no Brasil

Brazil has a relevant, although relatively unknown, special medicines programme that distributes high-cost products, such as drugs needed for cancer treatments. In 2009, the purchase of these medicines became the responsibility of the Brazilian Federal Government. Until then, there were no clear norms regarding the responsibilities, in terms of the management/financing of these medicines, of the Brazilian Federal Government and of the states themselves. This qualitative study analyses the policy process needed to transfer this programme to the central government. The study examines the reports of the Tripartite Commission between 2000 and 2012, and in-depth interviews with eleven key informants were conducted. The study demonstrates that throughout the last decade, institutional changes have been made in regard to the federal management of these programmes (such as recentralisation of the purchasing of medicines). It concludes that these changes can be explained because of the efficiency of the coordinating mechanisms of the Federal Government. These findings reinforce the idea that the Ministry of Health is the main driver of public health policies, and it has opted for the recentralisation of activities as a result of the development project implicit in the agenda of the Industrial and Economic Heal.

O Brasil possui um relevante, porém pouco conhecido, programa de medicamentos especializado, com distribuição de produtos de alto custo, como no caso do tratamento do câncer. Em 2009, a compra destes medicamentos passou a ser de responsabilidade federal. Até então, não existiam normas claras sobre as responsabilidades da União e estados na gestão e financiamento deste programa. O presente estudo qualitativo analisa a evolução do processo de transição deste programa para a esfera do governo federal. Através de uma consulta às atas da Comissão Intergestora Tripartite, de 2000 e 2012, e entrevistas com onze informantes, o estudo demonstrou que ao longo da última década foram realizadas alterações institucionais relevantes na gestão federativa destes programas, como a recentralização da compra destes medicamentos e a elaboração de critérios para a introdução de novos medicamentos neste programa, o que é explicável pela eficácia dos mecanismos de coordenação do governo federal. Esses achados reforçam a ideia de que o Ministério da Saúde, além de constituir o principal indutor de políticas públicas de saúde, tem optado pela recentralização de atividades, por força do projeto desenvolvimentista implícito na agenda do Complexo Econômico e Industrial da Saúde.

Propuesta de instrumento para la identificación de conocimientos sobre crecimiento y desarrollo infantil en egresados de la carrera de Medicina / Proposal of instrument for identification of knowledge on growth and development in medical graduates

Introducción: las consultas de Puericultura constituyen el principal escenario para promover un crecimiento y desarrollo óptimo del niño y el adolescente. Objetivo: elaborar una propuesta de instrumento que identifique los conocimientos sobre crecimiento y desarrollo en los egresados de la carrera de Medicina. Métodos: se realizó una investigación de desarrollo tecnológico en el campo de la Educación Médica Superior. Para la confección del cuestionario se seleccionó el tipo de preguntas de test objetivo. El instrumento elaborado fue sometido a criterio de expertos y a estudio piloto en un área de salud del municipio Boyeros. Resultados: las características de los expertos que participaron en la investigación facilitaron el análisis del cuestionario. Los términos utilizados resultaron de una adecuada comprensión para los participantes. El cuestionario permitió identificar áreas deficientes del conocimiento. Conclusiones: el instrumento que se propone abarca los contenidos de crecimiento y desarrollo en las diferentes etapas de la vida, y permite identificar los conocimientos adquiridos en los educandos.

Introduction: Childcare service is the main setting for the promotion of the optimal growth and development of the child and the adolescent. Objective: to prepare a proposal of instrument that identifies the knowledge on growth and development acquired by the medical graduates. Methods: a technological and development research in the field of higher medical education was conducted. For the preparation of the questionnaire, the type of objective test questions was selected. The final instrument was submitted to the experts´ criteria and was used in a pilot study in a health area of Boyeros municipality. Results: the characteristics of the experts included in the research made the analysis of the questionnaire easier. The terms used were correctly understood by the participants. The questionnaire also allowed detecting in what areas the lack of knowledge of students was evident. Conclusions: the suggested instrument comprises the contents of growth and development at the various stages of life and also allows identifying the amount of knowledge acquired by the students.

Concurso Nacional de Especialidades: principal incentivo para los médicos de atención primaria en Chile (2007-2011) / National Competition Specialties: main incentive for primary care physicians in Chile (2007-2011)

El Concurso Nacional de Becas de Especialidades para Médicos de Atención Primaria de Salud (APS) tiene como objetivo principal incentivar la incorporación de médicos generales y especialistas a la Atención Primaria de Salud en Chile, para mejorar el acceso y resolutividad en la atención de las 13 millones de personas que pertenecen al Sistema Público de Salud de nuestro país. Además, constituye la principal reivindicación obtenida en el acuerdo entre el Ministerio de Salud y el Colegio Médico de Chile del año 2007, donde se estableció un mínimo de 100 cupos de especialidades. La implementación de este concurso ha aumentado el interés de los médicos generales por trabajar en los consultorios públicos de nuestro país, incrementándose las horas médicas en la APS. Sin embargo, persiste un significativo déficit de éste tipo de horas en este nivel de atención, lo que se constituye un llamado de atención para potenciar este importante incentivo. En los dos últimos años han egresado de este programa 74 médicos que debieran estar desarrollando su especialidad en la red del Sistema Público de Salud con un periodo asistencial obligatorio de 6 años. Además, hay 204 médicos APS que se encuentran actualmente en formación de especialidad. Es muy importante que este programa de especialización cuente con un número significativo de cupos, considerando las especialidades que se requieren en la red de salud pública de nuestro país y en la APS. El objetivo de este trabajo consiste en evidenciar la importancia de la implementación de incentivos dentro de la carrera profesional de los médicos, en este caso el fomento de la especialización dentro del desarrollo profesional continuo de los médicos APS, lo que aporta beneficios tanto para los propios profesionales, como para el Sistema de Salud en su conjunto.

The National Scholarship Competition Specialties for Primary Care’s main objective is to encourage the inclusion of general practitioners and specialists to Primary Care Public Health System in Chile, to improve access and resoluteness in addressing the 13 million people who are registered in the offices of our country. It also constitutes the main claim in the agreement obtained between the Ministry of Health and the Medical College of Chile in 2007, which established a minimum of 100 seats. The implementation of this competition has increased the interest of general practitioners to work in public clinics in our country, increasing the hours medical PHC. However, there remains a significant deficit of hours medical care at this level, which is a clarion call to promote this important incentive. In the last two years this program has graduated 74 physicians who should be developing their expertise in the network of public health system with a period of 6 years compulsory care. In addition, there are 204 PHC doctors are currently in specialty training. It is very important that this specialization program counts with a significant number of places, considering the specialties that are required in the public health system of our country and the APS. The aim of this paper is to demonstrate the importance of the implementation of incentives within the medical career, in this case the development of specialization within the continuing professional development of physicians APS, which provides benefits for themselves professionals to the health system as a whole.