Fenomenología de la angustia moral: implicancias para la humanización de la educación y la práctica médica / Phenomenology of moral distress: implications for the humanization of medical education and practice

En el contexto de la salud, la angustia moral (AM) se refiere a las emociones negativas que surgen cuando una persona conoce el curso de acción correcto en una situación determinada pero no es capaz de seguirlo debido a impedimentos personales, jerárquicos o institucionales. La AM se ha relacionado con diversos problemas profesionales, tales como desorientación vocacional, baja motivación laboral, trato despersonalizado a los pacientes, abandono de funciones y cambios de especialidad o profesión. Si bien este fenómeno no ha sido suficientemente estudiado en Chile, se asume que existe e incluso habría aumentado durante la pandemia de COVID-19, siendo desconocidas sus repercusiones. En consecuencia, este artículo tiene como objetivos, en primer lugar, promover el estudio fenomenológico de la AM en nuestro país, considerando la importancia de prevenir su potencial impacto adverso en la salud mental de futuros profesionales, y, en segundo lugar, destacar la necesidad de incluir enfoques narrativos en la educación médica, a fin de desarrollar una aproximación más holística hacia la comprensión de los pacientes y de su condición de vulnerabilidad. En última instancia, se espera que el abordaje de las implicancias de la AM en la educación y la práctica médica contribuya con su humanización, optimizando la calidad de la atención en salud.

In the healthcare context, moral distress (MD) refers to the negative emotions that arise when a person knows the correct course of action in a given situation but is not able to follow it due to personal, hierarchical or institutional impediments. MD has been related to various professional problems, such as vocational disorientation, low work motivation, depersonalized treatment of patients, abandonment of duties, and changes of specialty or profession. Although this phenomenon has not been sufficiently studied in Chile, it presumably exists and would have even increased during the COVID-19 pandemic, leaving its repercussions unknown. Accordingly, this article has the objectives, firstly, to promote the phenomenological study of MD in our country, considering the importance of preventing its potential adverse impact on the mental health of future professionals, and, secondly, to highlight the need to include narrative approaches in medical education, in order to develop a more holistic approach to understanding patients and their condition of vulnerability. Ultimately, it is expected that addressing the implications of MD in medical education and practice will contribute to its humanization, optimizing the quality of healthcare.

The implementation of a required book club for medical students and faculty.

More medical schools are incorporating wellness activities and the medical humanities into their curriculum. Finding implementable programming that is feasible and enjoyable is challenging. Both student participants and faculty who might facilitate programs are busy with clinical and educational responsibilities. Book club discussions in general are an activity that bring people together and expose groups to literature. In medical education, informal books clubs have been shown to increase camaraderie and expose participants to topics in medicine that they may not have encountered without the structure of the group assignment. At one large private urban medical school, all fourth year medical students were required to participate in a one-time hour-long book discussion with a faculty member one week before Match Day 2021. This paper describes the implementation of that program and discusses survey results from 179 students who broadly indicated that the books were enjoyable, the discussions were enriching, and that the program should continue for future classes of medical students.

Entre ouvidos e palavras: um ensaio sobre medicina narrativa, redes sociais e humanização na Atenção Primária à Saúde / In between hearings and words: an essay on narrative medicine, social media, and humanization in Primary Health Care / Entre oídos y palabras: un ensayo sobre medicina narrativa, redes sociales y la humanización en la atención primaria de la salud

Este ensaio almejou refletir sobre a relação entre medicina narrativa, redes sociais e humanização a partir da utilização, por um dos autores, das redes sociais para compartilhamentos de histórias vivenciadas no contexto da Atenção Primária à Saúde. Questões acerca dos modelos de atenção em saúde vigentes, da escuta e da narrativa como dispositivos de humanização do cuidado e da emergência das redes sociais como potencializadoras da prática de saúde humanizada surgiram como importantes pontos a serem analisados à luz da literatura vigente. Ao fim, foram compartilhados apontamentos para utilização da medicina narrativa como ferramenta para uma prática humanizadora.(AU)

Abstract This essay reflects on the relationship between narrative medicine, social media, and humanization based on the use of social media by one of the authors to share experiences in the context of primary health care. Questions about prevailing health care models, listening, and narrative as dispositives of the humanization of care and the emergence of social media as drivers of humanized health practices arose as important points that need to be analyzed in the light of current literature. In the conclusion we present some considerations relating to the use of narrative medicine as a tool for promoting humanizing practices.(AU)

Resumen El objetivo de este ensayo fue reflexionar sobre la relación entre la medicina narrativa, las redes sociales y la humanización, a partir de la utilización, por parte de uno de los autores, de las redes sociales para compartición de historias vividas en el contexto de la Atención Primaria de la Salud. Surgieron preguntas sobre los modelos de atención de salud vigentes, de la escucha y de la narrativa como dispositivos de humanización del cuidado y de la emergencia de las redes sociales como potenciadoras de la práctica de salud humanizada como puntos importantes a analizar a la luz de la literatura vigente. Al final, se compartieron observaciones para la utilización de la medicina narrativa como herramienta para una práctica humanizadora.(AU)

Elaborar, compartilhar, narrar: uma análise narrativa de três abordagens de comunicação em Saúde / Elaborar, compartir, narrar: un análisis narrativo de tres abordajes de comunicación en salud / Elaborating, sharing, narrating: a narrative analysis of three approaches to health communication

Resumo A comunicação, a despeito de ser considerada um aspecto primordial no exercício da prática médica, não ganhou tanta proeminência na literatura e formação médica quanto os aspectos tecnológicos e biomédicos. Em resposta a esse contexto, surgiram campos de conhecimento que se propõem a refletir e fortalecer aspectos da comunicação entre o médico e o paciente. No presente artigo, realizamos uma análise narrativa da literatura de três abordagens de comunicação em Saúde: Grupos Balint, Método Clínico Centrado na Pessoa e Medicina Baseada em Narrativa. Foram destacados aproximações e distanciamentos entre tais abordagens, com o reconhecimento da potência própria de cada uma delas nos diversos contextos da prática médica.

Resumen La comunicación, a pesar de considerarse un aspecto primordial en el ejercicio de la práctica médica, no obtuvo tanto destaque en la literatura y en la formación médica como el que tuvieron los aspectos tecnológicos y biomédicos. Como respuesta a ese contexto, surgieron campos de conocimiento cuya propuesta es reflejar y fortalecer aspectos de la comunicación entre el médico y el paciente. En este artículo, realizamos un análisis narrativo de la literatura de tres abordajes de comunicación en salud: Grupos Balint, Método Clínico Centrado en la Persona y Medicina Basada en la Narrativa. Se destacaron aproximaciones y distanciamientos entre tales abordajes, con el reconocimiento de la potencia propia de cada una de ellas en los diversos contextos de la práctica médica.

Abstract Communication, despite being considered a key aspect in medical practice, has not received the corresponding attention both on literature and medical training as has the technological and biomedical aspects. As a reaction to this context emerged fields of knowledge proposing to reflect and strengthen aspects of communication between the physician and the patient. In this article, we perform a narrative analysis of the literature of three of such approaches to communication in health: the Balint Groups, the Patient Centered Care and Narrative-Based Medicine. The study highlights the approximations and distances between these approaches, along with the recognition of the potency of each of them in the different contexts of medical practice.

Advances in Shared Decision Making in Brazil: The role of patient autonomy in curriculum reform, health system and clinical care.

Clinical practice in Brazil has rapidly transformed. Doctor-patient relationships are the focus of these transformations, either within health policies or in the context of medical training. The Brazilian Curriculum Guidelines have emphasized the doctor-patient relationship as part of medical skills and competences, based on patient-centered care. In this article, we present the political advances in patient-centered care. In addition, we address an overview of the Brazilian status quo of decision aids tools. Finally, we share experiences in curriculum reform for the advances of communication skills and the interfaces with narrative medicine and the arts in curricular medical training as a means to advance towards the practice of shared decision making.

Profesionalismo y medicina narrativa / Professionalism and narrative medicine

This work is a bibliographical review of the challenges of professionalism in medical training. Medicine practiced with narrative competence, called narrative medicine, is proposed as a model for humane and effective medical practice. By virtue of the changes in the practice of medicine during the last years, professionalism values emerge as qualities that should reshape medicine. Several medical associations are redefining professionalism and insist that this issue should be included in the training curriculum. Thus, several medical education institutions are pursuing strategies to teach and assess professionalism. Modeling is still relevant as a learning strategy, but it must be tutored and directed. Also, timely and formative feedback appears as the most frequently suggested evaluative action. Both processes incorporate a personal reflective practice. Several recent studies suggest that a reflective experience is relevant for the formation of a professional identity. Narrative Medicine methodology emerges as an innovative strategy to address this issue, as it seeks to deliver valuable learning experiences to the students through reflection and the search for a new paradigm for medical practice.

Music in the epistemology of medicine

The pursuit of an integrated health education has led higher education institutions to question themselves on the ideal training for medical students which would foster a real connection with their surroundings: "educate to learn to live in the world and with others, knowing that the other person is both the same and different from me, oriented towards the same end: the shaping of the human being and the social good."1 Treating complex topics such as the processes underlying immunity, genetic transcription and metabolic diseases, among others, presents significant academic challenges for teachers and students in the learning process. However, there is an equally relevant hidden curriculum which may warrant the use of unconventional epistemological tools such as music, and which may be a good complement for acquiring clinical and humanistic skills, notably the capacity to develop semiological abilities and the capacity to develop empathy in critical health situations. From this point of view, the rehumanization of medicine has become a primary requirement today. Below, we will discuss three complex health situations described in salsa songs which analyze the underlying human emotions, as an invitation to explore the hidden curriculum behind the objectively viewed disease. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2243).

La búsqueda de una formación en salud integral ha llevado a que las instituciones de educación superior se cuestionen sobre la formación ideal que se debe brindar a los estudiantes de medicina en la que se fomente una conexión real con el entorno: "educar para aprender a vivir en el mundo y con el otro, a sabiendas de que el otro es una persona a la vez igual y diferente que yo, orientados a la misma finalidad: la conformación del ser humano y el bien social" 1. El abordaje de temas complejos como los procesos subyacentes a la inmunidad, la transcripción genética, las patologías metabólicas, entre otros, representan retos académicos importantes para los docentes y los estudiantes en el proceso del aprendizaje. Sin embargo, hay un currículo oculto que es igualmente relevante, y que puede ameritar el uso de herramientas epistemológicas no con vencionales, como la música, y que puede ser un buen complemento para adquirir las habilidades clínicas y humanísticas, entre las que destaca la capacidad de desarrollar habilidades semiológicas y la capacidad de desarrollar empatía frente a una situación crítica de salud. Desde este punto de vista, la rehumanización de la medicina se ha convertido en la actualidad en un requisito primordial. A continuación, se expondrán tres situaciones de salud complejas descritas en canciones de salsa, en las que se analiza las emociones humanas subyacentes, como una invitación a explorar el currículo oculto detrás de la enfermedad vista objetivamente. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2243).

O que estudantes nos contam sobre as entrevistas narrativas / What students tell us about narrative interviews

Romper com o modelo biomédico é necessário, e o ponto inicial pode vir com a compreensão da narrativa do usuário ou da usuária. Este estudo buscou avaliar a compreensão de estudantes de medicina das narrativas de adoecimento, utilizando a entrevista McGillIllness Narrative Interview (MINI). Trata-se de estudo exploratório, descritivo e qualitativo, realizado durante cinco semanas com 11 estudantes do quinto ano de uma universidade privada, no internato de Medicina de Família e Comunidade, que prestavam atendimento a 29 pessoas usuárias de unidades de saúde. Por meio de encontros individuais on-line, foram levantadas questões sobre essa experiência. Os relatos foram inseridos em núcleos argumentais, o que possibilitou o estabelecimento de relações com o referencial teórico da Medicina Narrativa, da Antropologia Médica e da Clínica Ampliada. Para os alunos e alunas houve uma nova experiência de entrevista clínica, uma valorização da narrativa e o desejo de incorporar uma abordagem mais ampliada à sua prática, embora não contemplem incorporar o MINI na sua forma integral, atribuindo a isso dificuldades na rotina médica. Acreditamos que o MINI pode colaborar com a aquisição de competências interpretativa e narrativa em estudantes, embora o ensino esteja ainda, emparte, vinculado ao modelo biomédico.

It is essential to break with the biomedical model. The starting point for that can come from the understanding of patients' narratives. This study sought to evaluate medical students' comprehension of illness narratives using the McGill Illness Narrative Interview (MINI). This is an exploratory, descriptive, and qualitative study, carried out with 11 fifth-year students at a private university in the internship of Family and Community Medicine, for five weeks, involving the care of 29 patients in health units. Through individual online meetings, questions were raised about the experience.The reports were inserted into categories, which allowed us to establish relationships among the theoretical referential elements of Narrative Medicine, Medical Anthropology, and Expanded Clinic. It was a new experience of clinical interviews for the students, with a new appreciation of narratives and a desire to incorporate a more extended approach to their practice, although they do not contemplate incorporating the MINI in its full form due to difficulties in the physician's routine. We believe that MINI can collaborate with the acquisition of interpretative and narrative competence in students, although teaching is still partly linked to the biomedical model.

Community Narrative as a Borderlands Praxis: Anzaldúa's Mestiza Consciousness as Explored in Cortez's Sexile.

I apply Gloria Anzaldúa's "borderlands theory" to Jamie Cortez's Sexile, an HIV/AIDS prevention publication created as a first-person narrative of the journey of queer, trans activist Adela Vasquez who fled to the US from Cuba in 1980. I argue that Sexile is a borderlands text and operationalizes Anzaldúa's mestiza consciousness at various levels- ranging from the essence of the text and what its existence represents to the literary techniques used in the telling of Adela's narrative. In the first half of this paper, I explore Anzaldúa's borderlands theory and the ethos of Sexile as a text, including Vázquez's story as inherently a borderland narrative; as a product of democratized knowledge; the praxis of the text's creation; and the technology of the graphic novel. Throughout the second half, I look more closely at the content of the text using close reading to explore notions of the "borderland" represented throughout Adela's narrative. Through both its content and the praxis of creation, Sexile represents the power of graphic medicine in illustrating the nuances of narratives at the interstices of marginalized identities and captures the multitudes and ambiguities of trauma, loss, rebirth, kinship, and joy at the margins.

A abordagem da medicina narrativa no processo de ensino-aprendizagem nas graduações das profissões da saúde / The narrative medicine approach in the teaching-learning process in undergraduate healthcare courses

Resumo: Introdução: Nas últimas décadas, mudanças importantes ocorreram nas ciências médicas, abrangendo desde a criação de novas condutas terapêuticas até reformulações de práticas relacionadas ao ensino, sobretudo no que concerne ao desenvolvimento de habilidades que promovam uma melhor relação entre o profissional de saúde e o paciente. Nesse contexto, a medicina narrativa (MN) surge como uma importante ferramenta transformadora da prática profissional na saúde por utilizar diferentes estratégias de comunicação para compreender as vivências dos indivíduos quanto aos seus processos de adoecimento. Objetivo: Este estudo teve como objetivo conhecer como a MN tem sido abordada no processo de ensino-aprendizagem nas graduações das profissões da saúde. Método: Trata-se de uma revisão integrativa da literatura, baseada na pergunta "Quais são os impactos do uso da MN no processo de ensino-aprendizagem nas graduações da área da saúde?". Foram incluídos artigos indexados nas bases de dados SciELO, LILACS, BVS e MEDLINE, publicados no período de janeiro de 2010 a junho de 2020 e disponíveis na íntegra. Resultado: Nove artigos foram selecionados e analisados, revelando que o uso e a aplicação da MN nas graduações das profissões da saúde são heterogêneos, com diferentes populações de estudo, metodologias de pesquisa, formas de abordagens e/ou cenário de aplicação. Contudo, a análise qualitativa evidenciou que a MN contribuiu de forma significativa para o processo de formação dos discentes e profissionais, estimulando o desenvolvimento de habilidades narrativas. Destacam-se a empatia na relação profissional de saúde-paciente, o respeito e reconhecimento da importância de outros profissionais da área no cuidado destinado à saúde e atitudes críticas e reflexivas nos cenários práticos, elementos que, na percepção dos sujeitos, só foram alcançados por meio do uso dessa abordagem. Conclusão: A formação do profissional de saúde requer competências narrativas que envolvem habilidades associadas à escuta e ao diálogo, bem como a capacidade de aprender e interpretar as vivências fornecidas pelos pacientes. No entanto, diante da escassez de estudos relacionados a essa temática, mais pesquisas são necessárias para melhor avaliar o uso dessa ferramenta como recurso didático nas graduações das profissões da saúde.

Abstract: Introduction: In recent decades, significant changes have occurred in the medical sciences, ranging from creating new therapeutic approaches to reformulations of practices related to teaching, above all, to develop skills that promote a better relationship between the health professional and the patient. In this context, narrative medicine (NM) emerges as an essential transforming tool in professional health practice because it uses different communication strategies to understand the experiences of individuals regarding their illness processes. Objective: This study aimed to knowing how in the teaching-learning process NM is addressed in undergraduate health care. Method: This is an integrative literature review based on the question "What are the impacts of the use of NM medicine in the teaching-learning process in undergraduate healthcare courses?". Publications in the form of complete articles were included, indexed in the SciELO, LILACS, BVS, and MEDLINE databases, published from January 2010 to June 2020, and full text available. Result: Nine articles were selected and analyzed, revealing that the use and application of NM in undergraduate health courses are heterogeneous with different study populations, research methodologies, forms of approaches and/or application scenarios. However, the qualitative analysis showed that the NM contributed significantly to training students and professionals, stimulating the development of narrative skills. Empathy in the professional health-patient relationship, respect, and recognition of the importance of other professionals in health care, critical and reflective attitudes in practical scenarios, elements that in the perception of the subjects stand out and were only achieved using this approach. Conclusion: The training of health professionals requires narrative skills that involve skills associated with listening and dialogue, as well as the ability to learn and interpret the experiences provided by patients. However, given the scarcity of studies related to this theme, more research is needed to better assess this tool's use as a teaching resource in undergraduate health.

[Cancer narrative and hermeneutical analysis]. / Narrativa del cáncer y análisis hermenéutico.

An existential analysis of the story that patients make related to the experience of suffering from cancer is presented. The objective of the study was to observe, describe and understand the way in which suffering reveals the temper of anguish and with it, the possibility of an authentic existence. Although this study only analyzes the report of two patients, the complete sample consists of 25 patients, all adults, of both sexes, aged between 40 and 70 years. The type of cancer varied, but in all cases it was treated with surgery, chemotherapy, and radiation therapy. Participation was voluntary and with consent. The interpretation and analysis was done by confronting the hermeneutical theories with the life stories of the patients.

Se presenta un análisis existenciario del relato que hacen los enfermos, relacionado con la experiencia de padecer cáncer. El objetivo del estudio fue observar, describir y comprender el modo en que el padecer desvela el temple de ánimo de la angustia y, con ello, la posibilidad de un existir auténtico. Aunque en este reporte solo se analiza el relato de dos pacientes, la muestra completa consta de 25 enfermos, todos adultos, de ambos sexos, rango de edad entre 40 y 70 años. El tipo de cáncer varió, pero en todos los casos se trató con cirugía, quimioterapia y radioterapia. La participación fue voluntaria y con consentimiento. La interpretación y el análisis se hizo confrontando las teorías hermenéuticas con los relatos de vida de los pacientes.

Narrativa del cáncer y análisis hermenéutico / Cancer narrative and hermeneutical analysis

Se presenta un análisis existenciario del relato que hacen los enfermos, relacionado con la experiencia de padecer cáncer. El objetivo del estudio fue observar, describir y comprender el modo en que el padecer desvela el temple de ánimo de la angustia y, con ello, la posibilidad de un existir auténtico. Aunque en este reporte solo se analiza el relato de dos pacientes, la muestra completa consta de 25 enfermos, todos adultos, de ambos sexos, rango de edad entre 40 y 70 años. El tipo de cáncer varió, pero en todos los casos se trató con cirugía, quimioterapia y radioterapia. La participación fue voluntaria y con consentimiento. La interpretación y el análisis se hizo confrontando las teorías hermenéuticas con los relatos de vida de los pacientes.

An existential analysis of the story that patients make related to the experience of suffering from cancer is presented. The objective of the study was to observe, describe and understand the way in which suffering reveals the temper of anguish and with it, the possibility of an authentic existence. Although this study only analyzes the report of two patients, the complete sample consists of 25 patients, all adults, of both sexes, aged between 40 and 70 years. The type of cancer varied, but in all cases it was treated with surgery, chemotherapy, and radiation therapy. Participation was voluntary and with consent. The interpretation and analysis was done by confronting the hermeneutical theories with the life stories of the patients.

Relatos sobre COVID-19 de profesionales de la salud en un hospital / Stories about covid-19 from health professionals in a hospital

Introducción: la pandemia de COVID-19 impone a los profesionales de la salud: altas exigencias y modificaciones en el modo de vincularse con pacientes, pares y familiares. Estos cambios implican consecuencias emocionales tales como el incremento del nivel de estrés y síntomas de ansiedad y de depresión. Objetivo: describir un proyecto interdisciplinario creado bajo el modelo de la Medicina Narrativa dirigido a habilitar el relato de la experiencia de profesionales de la salud pertenecientes a un hospital general privado de alta complejidad de la ciudad de Buenos Aires durante la pandemia de COVID-19. Metodología: se creó una lista de correo y se convocó a profesionales del hospital a realizar una producción escrita, oral o gráfica que represente su experiencia durante la pandemia. Luego, el material recibido se envió a la misma lista de distribución con frecuencia semanal. En cada correo se renovó la invitación a narrar lo vivido o comentar los relatos de otros. Resultados: en el transcurso de siete semanas se recibieron diez producciones individuales: ocho textos, un audio y un gráfico. Los principales temas tratados pudieron agruparse en tres ejes: sala COVID, comunidad y telemedicina. Los autores fueron profesionales de Medicina, Enfermería, Psicología y de Puericultura. Conclusión: desarrollamos un proyecto bajo el modelo de la Medicina Narrativa que permitió a profesionales narrar su experiencia durante la pandemia de COVID-19, habilitando la posibilidad de poner en palabras lo vivido, reflexionar sobre modelos de actuación y elaborar el desgaste emocional generado por el contacto permanente con el dolor y el sufrimiento. (AU)

Introduction: the COVID-19 pandemic imposes high demands on health professionals and changes in the way they relate to patients, peers and family members. These changes involve emotional consequences such as increased stress levels, symptoms of anxiety and depression. Objective: to describe an interdisciplinary project created under the Narrative Medicine model aimed at enabling the reporting of the experience of health professionals belonging to a highly complex private general hospital in the city of Buenos Aires during the COVID-19 pandemic. Methodology: a mailing list was created and hospital professionals were invited to make a written, oral or graphic production that represents their experience during the pandemic. Then, the received material was sent to the same distribution list on a weekly basis. In each email, the invitation to narrate what was experienced or to comment on the stories of others was renewed. Results: over the course of seven weeks, ten individual productions were received: eight texts, one audio and one graphic. The main topics discussed could be grouped into three axes: COVID room, community and telemedicine. The authors were professionals from Medicine, Nursing, Psychology and Childcare. Conclusion: we developed a project under the Narrative Medicine model that allowed professionals to tell their experience during the covid 19 pandemic, enabling the possibility of putting into words what was experienced, reflecting on models of action and elaborating on the emotional exhaustion generated by permanent contact with pain and suffering. (AU)

Brazil's Community Health Workers Practicing Narrative Medicine: Patients' Perspectives.

BACKGROUND: Narrative medicine (NM) encourages health care providers to draw on their personal experiences to establish therapeutic alliances with patients of prevention and care services. NM medicine practiced by nurses and physicians has been well documented, yet there is little understanding of how community health workers (CHWs) apply NM concepts in their day-to-day practices from patient perspectives. OBJECTIVE: To document how CHWs apply specific NM concepts in Brazil's Family Health Strategy (FHS), the key component of Brazil's Unified Health System. DESIGN: We used a semi-structured interview, grounded in Charon's (2001) framework, including four types of NM relationships: provider-patient, provider-colleague, provider-society, and provider-self. A hybrid approach of thematic analysis was used to analyze data from 27 patients. KEY RESULTS: Sample: 18 females; 13 White, 12 "Pardo" (mixed races), 12 Black. We found: (1) provider-patient relationship-CHWs offered health education through compassion, empathy, trustworthiness, patience, attentiveness, jargon-free communication, and altruism; (2) provider-colleague relationship-CHWs lacked credibility as perceived by physicians, impacting their effectiveness negatively; (3) provider-society relationship-CHWs mobilized patients civically and politically to advocate for and address emerging health care and prevention needs; (4) provider-self relationship-patients identified possible low self-esteem among CHWs and a need to engage in self-care practices to abate exhaustion from intense labor and lack of resources. CONCLUSION: This study adds to patient perspectives on how CHWs apply NM concepts to build and sustain four types of relationships. Findings suggest the need to improve provider-colleague relationships by ongoing training to foster cooperation among FHS team members. More generous organizational supports (wellness initiatives and supervision) may facilitate the provider-self relationship. Public education on CHWs' roles is needed to enhance the professional and societal credibility of their roles and responsibilities. Future research should investigate how CHWs' personality traits may influence their ability to apply NM.

Análise de narrativas produzidas por estudantes de Medicina por meio da distribuição de pílulas literárias em uma sala de espera / Analysis of narratives produced by medical students from the distribution of literary pills in a waiting room / Análisis de narrativas producidas por estudiantes de Medicina a partir de la distribución de píldoras literarias en una sala de espera

Os autores apresentam e discutem uma atividade do projeto de extensão Prescrevendo Histórias: desenvolvimento de competência narrativa em estudantes de Medicina, da Universidade do Estado do Rio de Janeiro, Brasil. O foco do artigo é a descrição da metodologia desenvolvida: distribuição de pílulas literárias na sala de espera de um ambulatório e produção de narrativas por meio da experiência, bem como sua análise. O artigo está dividido em seções. Inicialmente são apresentados a dinâmica de desenvolvimento da atividade e o procedimento metodológico engendrado para a análise do material produzido por encontros virtuais do grupo. A seguir, é abordada a análise das 25 narrativas, com destaque para as temáticas, os recursos linguísticos e as vozes presentes. Os autores concluem que o recurso didático-pedagógico apresentado possibilitou a incorporação de valores humanísticos à formação dos estudantes de Medicina. (AU)

The authors present and discuss an activity of the extension project "Prescribing stories: development of narrative competence in medical students, from the State University of Rio de Janeiro, Brazil". The focus of the article is the description of the developed methodology: distribution of literary pills in the waiting room of an outpatient clinic and production of narratives from this experience, as well as the analysis of the created narratives. The article is divided into sections. Initially, the dynamics of the activity's development and the methodological procedure conceived for the analysis of the analysis of the material produced are presented, based on virtual group meetings. Then, the analysis of the 25 narratives is addressed, emphasizing their voices, themes and linguistic resources The authors conclude that the in question didactic-pedagogical resource enabled the incorporation of humanistic values in the education of medical students. (AU)

Los autores presentan y discuten una actividad del proyecto de expansión Prescribiendo historias: desarrollo de competencia narrativa en estudiantes de medicina, de la Universidad del Estado de Río de Janeiro, Brasil. El enfoque del artículo es la descripción de la metodología desarrollada: distribución de píldoras literarias en la sala de espera de un ambulatorio y producción de narrativas a partir de la experiencia, así como de su análisis. El artículo se divide en secciones. Inicialmente se presentan la dinámica de desarrollo de la actividad y el procedimiento metodológico engendrado para el análisis del material producido, a partir de encuentros virtuales del grupo. A seguir, se aborda el análisis de las 25 narrativas, con destaque para las temáticas, los recursos lingüísticos y las voces presentes. Los autores concluyen que el recurso didáctico-pedagógico presentado posibilitó la incorporación de valores humanísticos a la formación de los estudiantes de Medicina. (AU)

Clinical records: the medical writing from the patient's story to the medical narrative.

A historical follow-up on the medical diaries about the patient is made, from the Hippocratic texts to the appearance of the current canon of the clinical history formulated by Boerhaave in the seventeenth century, through the medieval consilia and the curationes and observationes of the Renaissance; and it is discussed how much the patient's story is present in those writings. It is postulated that the medical narrative that starts from adequately listening to the patient and his story, and adopts a literary workshop format, it is a pedagogical tool that contributes to comprehensive medical training, and offers the patient the opportunity to be treated in an empathic and humanized environment.

Se hace un seguimiento histórico a los escritos médicos sobre el paciente, desde los textos hipocráticos hasta la aparición del canon actual de historia clínica formulado por Boerhaave en el siglo XVII, pasando por los consilia medievales y las curationes y observationes del renacimiento; y se discute qué tanto el relato del paciente está presente en esos escritos. Se postula que la narrativa médica que parte de escuchar adecuadamente al paciente y su historia, y se trabaja en formato de taller literario, es una herramienta pedagógica que contribuye a la formación médica integral y ofrece la posibilidad de que el paciente pueda ser tratado en un medio empático y humanizado.

Aproximación al currículum oculto a través de la medicina narrativa en la formación de estudiantes de Medicina / Approach to the hidden curriculum through narrative medicine in the training of medical students

Introducción. Currículum oculto son aquellos contenidos aprendidos que no pertenecen al currículum formal. La medicina narrativa permite conocer las experiencias de profesionales de la salud. Aproximarse al currículum oculto permitiría modificar o reforzar instancias de aprendizaje no formal.Objetivo. Analizar producciones narrativas de estudiantes de Medicina para identificar contenidos del currículum oculto.Población y métodos. Estudio de corte transversal con estudiantes de la materia Pediatría durante 2017.Resultados. Los 14 estudiantes de una cursada realizaron 50 narraciones. El 53 % correspondieron al contexto internación; el 17 %, a atención ambulatoria; el 17 %, a la central de emergencias, y el 13 %, a neonatología. Los principales contenidos fueron comunicación médico-paciente, inclusión de la familia en la consulta pediátrica, empatía, enfermedad crónica en los niños y comunicación de malas noticias.Conclusiones. Las producciones narrativas permitieron aproximarse al currículum oculto a través de reflexiones sobre el accionar profesion

Introduction. Hidden curricula are those contents learned that do not belong to the formal curriculum. Narrative medicine allows knowledge of health professionals ́ experiences. Approaching to the hidden curriculum can allow modifying or reinforcing instances of the non-formal learning.Objective. Analyze narrative medical students ́ productions to identify hidden curriculum contents.Population and methods. A cross-sectional study was conducted with Pediatric students during 2017.Results. All the students of the course (14) participated and performed 50 narrative productions: 53 % corresponded to the hospitalization context, 17 % to ambulatory care, 17 % to the emergency center and 13 % to neonatology.The main topics described were doctor-patient communication, importance of family inclusio in the pediatric consultation, empathy, impact of chronic disease in children and communication of bad news.Conclusions. Narrative productions allowed an approximation to the hidden curriculum through reflections on professional action

[Approach to the hidden curriculum through narrative medicine in the training of medical students]. / Aproximación al currículum oculto a través de la medicina narrativa en la formación de estudiantes de Medicina.

INTRODUCTION: Hidden curricula are those contents learned that do not belong to the formal curriculum. Narrative medicine allows knowledge of health professionals' experiences. Approaching to the hidden curriculum can allow modifying or reinforcing instances of the nonformal learning. OBJECTIVE: Analyze narrative medical students' productions to identify hidden curriculum contents. POPULATION AND METHODS: A cross-sectional study was conducted with Pediatric students during 2017. RESULTS: All the students of the course (14) participated and performed 50 narrative productions: 53 % corresponded to the hospitalization context, 17 % to ambulatory care, 17 % to the emergency center and 13 % to neonatology. The main topics described were doctor-patient communication, importance of family inclusion in the pediatric consultation, empathy, impact of chronic disease in children and communication of bad news. CONCLUSIONS: Narrative productions allowed an approximation to the hidden curriculum through reflections on professional actions.

Introducción. Currículum oculto son aquellos contenidos aprendidos que no pertenecen al currículum formal. La medicina narrativa permite conocer las experiencias de profesionales de la salud. Aproximarse al currículum oculto permitiría modificar o reforzar instancias de aprendizaje no formal. Objetivo. Analizar producciones narrativas de estudiantes de Medicina para identificar contenidos del currículum oculto. Población y métodos. Estudio de corte transversal con estudiantes de la materia Pediatría durante 2017. Resultados. Los 14 estudiantes de una cursada realizaron 50 narraciones. El 53 % correspondieron al contexto internación; el 17%, a atención ambulatoria; el 17 %, a la central de emergencias, y el 13 %, a neonatología. Los principales contenidos fueron comunicación médico-paciente, inclusión de la familia en la consulta pediátrica, empatia, enfermedad crónica en los niños y comunicación de malas noticias. Conclusiones. Las producciones narrativas permitieron aproximarse al currículum oculto a través de reflexiones sobre el accionar profesional.

Clinical records: the medical writing from the patient's story to the medical narrative / Historia clínica: la escritura médica del relato del paciente a la narrativa médica

Abstract A historical follow-up on the medical diaries about the patient is made, from the Hippocratic texts to the appearance of the current canon of the clinical history formulated by Boerhaave in the seventeenth century, through the medieval consilia and the curationes and observationes of the Renaissance; and it is discussed how much the patient's story is present in those writings. It is postulated that the medical narrative that starts from adequately listening to the patient and his story, and adopts a literary workshop format, it is a pedagogical tool that contributes to comprehensive medical training, and offers the patient the opportunity to be treated in an empathic and humanized environment.

Resumen Se hace un seguimiento histórico a los escritos médicos sobre el paciente, desde los textos hipocráticos hasta la aparición del canon actual de historia clínica formulado por Boerhaave en el siglo XVII, pasando por los consilia medievales y las curationes y observationes del renacimiento; y se discute qué tanto el relato del paciente está presente en esos escritos. Se postula que la narrativa médica que parte de escuchar adecuadamente al paciente y su historia, y se trabaja en formato de taller literario, es una herramienta pedagógica que contribuye a la formación médica integral y ofrece la posibilidad de que el paciente pueda ser tratado en un medio empático y humanizado.

Declaração de óbito domiciliar na Atenção Primária à Saúde: acolhendo a morte no lar / Certificado de defunción domiciliaria en la Atención Primaria de la Salud: acogida de la muerte en el hogar / Home death certificate in Primary Health Care: welcoming death at home

A Atenção Primária à Saúde (APS) é um cenário capaz de produzir cuidado em todas as fases da vida, desde o nascer ao morrer. Porém, o cuidado de saúde de pessoas gravemente enfermas requer uma abordagem complexa e holística desses sujeitos e famílias, sendo muitas vezes prestado em domicílio. Uma das atribuições relacionadas aos cuidados em fim de vida é a emissão da declaração de óbito quando este ocorre em domicílio. Pela perspectiva de uma médica de Família e Comunidade, relatou-se, de modo narrativo e reflexivo, uma experiência de um atendimento domiciliar para emissão de declaração de óbito. A partir dessa narrativa, discutiu-se sobre como a visita para declaração de óbito nos convida a entrar em um território repleto de subjetividades, que nos evoca muitas reflexões sobre o processo de morte e morrer, provocando transformações em nossa vida pessoal e profissional.(AU)

La Atención Primaria de la Salud es un escenario capaz de producir cuidado en todas las fases de la vida, desde el nacimiento hasta la muerte. No obstante, el cuidado de la salud de personas gravemente enfermas requiere un abordaje complejo y holístico de esos sujetos y familias, siendo muchas veces realizada a domicilio. Una de las atribuciones relacionadas con los cuidados al final de la vida es la emisión del certificado de defunción, cuando la misma ocurre en el domicilio. Bajo la perspectiva de una médica deFamilia y Comunidad, se relató de modo narrativo y reflexivo una experiencia de una atención domiciliaria para emisión de certificado de defunción. A partir de esa narrativa, se discutió sobre cómo la visita para el certificado de defunción nos invita a entrar en un territorio repleto de subjetividades que nos evoca muchas reflexiones sobre el proceso de la muerte y el morir, causando transformaciones en nuestra vida personal y profesional.(AU)

Primary Health Care is a scenario capable of producing care at all stages of life, from birth to death. However, the health care of severely ill people requires a complex and holistic approach to these subjects and families, often being provided at home. One of the duties related to end-of-life care is the issuance of a death certificate when death occurs at home. From the perspective of a Family and Community doctor a narrative and reflective experience is reported by a home care service for issuing a death certificate. From this narrative we discussed how the visit for the issuance of the death certificate invites us into a territory full of subjectivities, which evokes many reflections on the process of death and dying, causing changes in our lives both personally and professionally.(AU)