Resident training in psychopathology and uncertainty in a clinical situation.

The central theme of this article is the way in which psychiatry physicians-in-training deal with uncertainty in the discussion of clinical cases in Mexico. Methodologically, it is approached from the field of clinical ethnography and the narrative interpretation of plots in performative actions where there are sequences of communicative exchanges. In this way, it focuses on a detailed description of situations where clinical cases are reviewed to decipher, explain, and understand intersubjective meanings in the face of the emergence of uncertainty, its management, and the implications on decisions and actions. The study finds that limitations within the field of psychiatry lie in the nosographic construction of disease and its translation into the diagnostic hypotheses made by clinicians, where there are wide margins of ambiguity. The strategies implemented in the face of uncertainty are use of drugs, the collegiate review of the case, and utilization of intuition as a spontaneous, preconscious daily practice. The specific case described here provides a microscopic observation of the complex scenarios in which uncertainty occurs in educational and teaching processes, clearly revealing how patient care is articulated. The narratives and their interpretation are materials for training/curriculum and psychiatric clinical practice.

Modelo de rol, experiencias y capacidades comunicativas en estudiantes de medicina / Role model, experiences and communicative skills in medical students

Introducción: La comunicación se ha definido como un elemento central y eje transversal de los currículos médicos a nivel mundial. Además, en el proceso formativo del estudiante de medicina, el efecto de los modelos de rol docente se reconoce como factor clave. Objetivo: Revisar conceptualmente el modelo de rol en relación con el currículo en comunicación, y su influencia en el proceso de enseñanza y aprendizaje de los estudiantes de medicina. Métodos: Se llevó a cabo una revisión bibliográfica sistemática de artículos científicos disponibles en las bases de datos EbscoHost y PubMed, así como de textos de educación médica, teniendo en cuenta las palabras clave validadas en el tesauro DeCs. Resultados: Se presentó la definición y la importancia del modelo de rol, la identidad, las características y las capacidades pedagógicas del profesor; además se expusieron conceptos como "modelo de rol positivo" y "antimodelo". También se mostró el contexto en el que se desarrollaba el rol docente en función de la experiencia de comunicación, y los escenarios, los momentos y las formas con los que se lograron las capacidades, competencias y habilidades comunicativas en los estudiantes, lo que demostró que el aprendizaje por medio del ejemplo de los profesores resultaba fundamental. Conclusiones: Se necesita propiciar procesos de formación docente como medio para resignificar el sentido de los modelos de rol en la práctica comunicativa del estudiante. El modelo de rol y su influencia en el desarrollo de capacidades en la comunicación y el profesionalismo se constituyen como perspectiva para la investigación en educación médica(AU)

Introduction: Communication has been defined as a key element and cross-sectional pivot of medical curricula worldwide. Also, in the training process of the medical student, the effect of professorial role models is recognized as a key factor. Objective: To review, conceptually, the role model in association with to the communicative curriculum, as well as its influence on the teaching and learning process of medical students. Methods: A systematic bibliographic review was carried out of scientific articles available in the databases EbscoHost and PubMed, as well as medical education texts, taking into account the keywords validated on the Health Sciences Descriptors (DeCS). Results: We presented the definition and importance of the role model, as well as the professor's identity, characteristics and pedagogical capacities. Concepts such as positive role model and antimodel were also exposed. We also showed the context in which the teaching role was developed based on the communication experience, as well as the settings, moments and ways by which the students' communication capacities, competences and abilities were achieved, which showed that learning through the professorial model was essential. Conclusions: It is necessary to promote professorial training processes as means to redefine the significance of role models in the student's communicative practice. The role model and its influence on the development of communication skills and professionalism constitute a perspective for research in medical education(AU)

Training of general practitioners, a Mexican medical school curriculum evaluation / Formación de médicos generales, evaluación curricular en una escuela mexicana de medicina

Background: Educational curricula require constant improvement to respond to the needs of students, institutions and society. Objective: To evaluate the Plan de Estudios 2010 of the Facultad de Medicina de la Universidad Nacional Autónoma de México. Methods: Documentary and qualitative study of three phases. First, revision of trends of general medicine in special databases and comparison of curricula between universities. Second, focus groups with clinical teachers and basic sciences to investigate experiences and opinions in relation to trends in general medicine. Third, a "Generalists Committee" was convened to whom the results were presented (phase one and two) and the recommendations were adapted to adapt the results to the general practitioner's context. The participants were informed about the research objective and their participation was voluntary, the anonymity of theirs comments was protected. Results: The trend towards specialization in clinical practice defines the future of general medicine, and the administrative uses have an impact on the practices of the general practitioner and on the patient's medical relationship. Conclusion: Various aspects mainly educational and assistance hindered the quality of the practice of general medicine.

Introducción: los currículos educativos requieren estar en constante perfeccionamiento para responder a las necesidades de estudiantes, instituciones y de la sociedad. Objetivo: evaluar el Plan de Estudios 2010 de la carrera de medicina de la Facultad de Medicina de la Universidad Nacional Autónoma de México. Métodos: estudio documental y cualitativo, de tres fases. En la primera se revisaron las tendencias de la medicina general en bases de datos especializadas y se compararon los planes de estudios entre universidades. En la segunda, se realizaron grupos focales con docentes clínicos y de ciencias básicas para indagar experiencias y opiniones en relación con las tendencias de la medicina general. En la tercera, se convocó a un "Comité de Generalistas" a quienes se les presentaron los resultados de las fases anteriores, y se realizaron las recomendaciones pertinentes para adecuar los resultados al contexto del médico general. La participación de los entrevistados fue voluntaria, fueron informados sobre el objetivo de investigación y se resguardó el anonimato de sus testimonios. Resultados: la tendencia hacia la especialidad en la práctica clínica define el futuro de la medicina general; asimismo, los intereses administrativos repercuten en las prácticas del médico general y en la relación médico-paciente. Conclusión: diversos aspectos, principalmente educativos y asistenciales, obstaculizan la calidad de la práctica de la medicina general.

Specific entrustable professional activities for undergraduate medical internships: a method compatible with the academic curriculum.

BACKGROUND: Competency-based education has been considered the most important pedagogical trend in Medicine in the last two decades. In clinical contexts, competencies are implemented through Entrustable Professional Activities (EPAs) which are observable and measurable. The aim of this paper is to describe the methodology used in the design of educational tools to assess students´ competencies in clinical practice during their undergraduate internship (UI). In this paper, we present the construction of specific APROCs (Actividades Profesionales Confiables) in Surgery (S), Gynecology and Obstetrics (GO) and Family Medicine (FM) rotations with three levels of performance. METHODS: The study considered a mixed method exploratory type design, a qualitative phase followed by a quantitative validation exercise. In the first stage data was obtained from three rotations (FM, GO and S) through focus groups about real and expected activities of medical interns. Triangulation with other sources was made to construct benchmarks. In the second stage, narrative descriptions with the three levels were validated by professors who teach the different subjects using the Delphi technique. RESULTS: The results may be described both curricular and methodological wise. From the curricular point of view, APROCs were identified in three UI rotations within clinical contexts in Mexico City, benchmarks were developed by levels and validated by experts' consensus. In regard to methodological issues, this research contributed to the development of a strategy, following six steps, to build APROCs using mixed methods. CONCLUSIONS: Developing benchmarks provides a regular and standardized language that helps to evaluate student's performance and define educational strategies efficiently and accurately. The university academic program was aligned with APROCs in clinical contexts to assure the acquisition of competencies by students.

[Competence development in undergraduate medical schools: a model with entrusted professional activities]. / Desarrollo de competencias en el pregrado: un modelo con actividades profesionales confiables (APROC).

INTRODUCTION: Today´s relevant educational models emphasize that a great part of learning be situated and reflexive; one of those is the Entrusted Professional Activities model. The study objective was to develop a model that integrates Entrusted Professional Activities with a medical school curriculum. METHODS: From October 2012 a multidisciplinary group met to develop a model with the specialty of obstetrics and gynecology. From two published models of Entrusted Professional Activities and the curriculum of a school of medicine, blocks, units, and daily clinical practice charts were developed. The thematic content of the curriculum was integrated with the appropriate milestones for undergraduate students and the clinical practice needed to achieve it. RESULTS: We wrote a manual with 37 daily clinical practice charts for students (18 of gynecology and 19 of obstetrics) and 37 for teachers. Each chart content was the daily clinical practice, reflection activities, assessment instruments, and bibliography. CONCLUSIONS: It is feasible to combine a model of Entrusted Professional Activities with an undergraduate curriculum, which establishes a continuum with postgraduate education.

A typology of uncertainty derived from an analysis of critical incidents in medical residents: A mixed methods study.

BACKGROUND: Medical uncertainty is inherently related to the practice of the physician and generally affects his or her patient care, job satisfaction, continuing education, as well as the overall goals of the health care system. In this paper, some new types of uncertainty, which extend existing typologies, are identified and the contexts and strategies to deal with them are studied. METHODS: We carried out a mixed-methods study, consisting of a qualitative and a quantitative phase. For the qualitative study, 128 residents reported critical incidents in their clinical practice and described how they coped with the uncertainty in the situation. Each critical incident was analyzed and the most salient situations, 45 in total, were retained. In the quantitative phase, a distinct group of 120 medical residents indicated for each of these situations whether they have been involved in the described situations and, if so, which coping strategy they applied. The analysis examines the relation between characteristics of the situation and the coping strategies. RESULTS: From the qualitative study, a new typology of uncertainty was derived which distinguishes between technical, conceptual, communicational, systemic, and ethical uncertainty. The quantitative analysis showed that, independently of the type of uncertainty, critical incidents are most frequently resolved by consulting senior physicians (49 % overall), which underscores the importance of the hierarchical relationships in the hospital. The insights gained by this study are combined into an integrative model of uncertainty in medical residencies, which combines the type and perceived level of uncertainty, the strategies employed to deal with it, and context elements such as the actors present in the situation. The model considers the final resolution at each of three levels: the patient, the health system, and the physician's personal level. CONCLUSIONS: This study gives insight into how medical residents make decisions under different types of uncertainty, giving account of the context in which the interactions take place and of the strategies used to resolve the incidents. These insights may guide the development of organizational policies that reduce uncertainty and stress in residents during their clinical training.

[Educational model to develop trustworthy professional activities]. / Modelo educativo para desarrollar actividades profesionales confiables (MEDAPROC).

BACKGROUND: The reorganization of the national health system (SNS), enforces reflection and transformation on medical education in clinical contexts. The study presents an educational model to develop entrusted professionals activities (MEDAPROC) to train human resources in health with reliable knowledge, skills and attitudes to work in the shifting scenario of the SNS. METHODS: The paper discusses international and national documents on skills in medicine. Based on the analysis of 8 domains, 50 skills and 13 entrusted professional activities (RPA) proposed by the Association of the American Medical College (AAMC) we propose a curriculum design, with the example of the undergraduate program of Gynecology and Obstetrics, with the intention to advance to internship and residency in a continuum that marks milestones and clinical practices. RESULTS: The pedagogical design of MEDAPROC was developed within three areas: 1) proposal of the AAMC; 2) curricular content of programs in pre and postgraduate education 3) organization of the daily agenda with academic mechanisms to develop the competencies, cover program items and develop clinical practice in deliberate learning activities, as well as milestones. CONCLUSION: The MEDAPROC offers versatility, student mobility and curricular flexibility in a system planed by academic units in diverse clinical settings.

Introducción: la reorganización del Sistema Nacional de Salud (SNS), obliga a reflexionar y modificar la formación médica en los contextos clínicos. El estudio presenta la propuesta Modelo Educativo para Desarrollar Actividades Profesionales Confiables (MEDAPROC) para formar recursos humanos en salud con conocimientos, habilidades y actitudes confiables para desempeñarse en el escenario cambiante del SNS. Métodos: se examinaron los documentos internacionales y nacionales sobre competencias en medicina. Con base en el análisis de los 8 dominios, las 50 competencias y las 13 Actividades Profesionales Confiables (APROC) propuestas por la Association of the American Medical College (AAMC) se realizó un diseño curricular con el ejemplo del programa de Ginecología y Obstetricia de pregrado. Un grupo focal con 5 ginecólogos expertos, profesores de la especialidad realimentaron las competencias y los programas. Resultados: Se elaboró el diseño pedagógico del MEDAPROC con tres áreas: 1) propuesta de la AAMC; 2) contenidos curriculares de los programas en pre y posgrado, y 3) hitos y planeación de la agenda del día con dispositivos pedagógicos para desarrollar las competencias, cubrir temas del programa y desarrollar la práctica clínica en actividades deliberadas para el aprendizaje teórico/práctico. Conclusión: El MEDAPROC ofrece versatilidad, movilidad estudiantil y flexibilidad curricular en un sistema por bloques y no por sedes de adscripción.

[Correlations between the dimensions of clinical learning environments from the perspective of medical residents]. / Correlaciones entre las dimensiones de los ambientes clínicos de aprendizaje desde la percepción de los médicos residentes.

OBJECTIVES: The aim of the present study was to establish correlations between the dimensions of clinical learning environments (ACA) considering variables like: health institutions, hospital offices, specialty, and year of residency. METHODS: 4,189 doctors were evaluated through an online survey in 2012. RESULTS: The results revealed that the dimension of "educational processes" correlated best with others; specialties with the best ACA from the view of the medical residents were Internal Medicine and Surgery; and the third year residents had less favorable perceptions of their ACA. CONCLUSIONS: The pursuance of the academic program is relevant to physicians in training and teachers play an important role in the educational process.

[Construction, validation and use of an instrument developed to assess learning clinical environments in medical specialties]. / Construcción y validación de un instrumento para evaluar ambientes clínicos de aprendizaje en las especialidades médicas.

INTRODUCTION: Clinical education is an essential component of medical training and takes place in relatively adequate learning environments. OBJECTIVE: Build and validate an instrument specific for the assessment of factors influencing a clinical learning environment. MATERIAL AND METHODS: A Likert-type questionnaire was designed and its content was validated, while statistical trials were applied to it to determine its psychometric properties. The instrument was refined and assessed twice (a pilot of 122 cases on October 2011 and the study of 4,189 PUEM residents on March 2012). It consists of 28 items, distributed in four dimensions: interpersonal relations (IR), teaching processes (TP), institutional culture (IC), and service dynamics (SD). RESULTS: Cronbach's α of the whole pilot questionnaire after item refinement and 4,189 case study was 0.94 and 0.96, respectively. The percentage of total variance explained by the first component was 48 and 46%, respectively. CONCLUSIONS: The reliability and validity of the whole questionnaire and by dimension was adjusted to assess clinical learning environments in Mexican contexts and allows ranking specialized medical departments.

Las actividades docentes de los profesores clínicos del PUEM desde la perspectiva de sus residentes / PUEM's clinical professors' teaching activities from their residents' perspective

Introducción: Se busca describir las actividades docentes en el ámbito clínico desde la perspectiva de los residentes del PUEM. Objetivos: 1) Identificar la frecuencia con que los profesores clínicos realizan actividades educativas en 4 áreas: docencia, supervisión, organización y relaciones interpersonales, 2) distinguir por especialidad el desempeño de los instructores, 3) indagar diferencias en la evaluación del docente según el grado académico de los residentes. Material y métodos: La "Encuesta de Alumnos del PUEM 2010" incluyó en la sección del desempeño docente 13 preguntas de frecuencia y 2 de valoración. Se consideraron actividades educativas de las 4 áreas mencionadas en 10 especialidades. La muestra fue de 1816 casos y se buscaron asociaciones significativas (p < 0.05) entre las variables. Resultados: En las opciones de respuesta "siempre" y "casi siempre", las relaciones interpersonales fueron las mejor valoradas (> 80%), la organización continua de actividades académicas y asistenciales fue mencionada en más de 2 terceras partes de las respuestas. La frecuencia de actividades docentes vinculadas a la estructura curricular, y la supervisión se ubicaron en promedio por debajo de la media. Las mejores calificaciones fueron para los profesores de Medicina Familiar y las más bajas para Ortopedia. Por grado académico, R1 y R5 consideraron que la labor docente fue más constante y los R2 menos. Discusión: La relación personal entre profesores y residentes es adecuada y los estudiantes se perciben integrados a sus servicios; no obstante, el apego a los programas académicos y la supervisión no sucede con suficiente frecuencia.

Introduction: The aim is to describe the teaching activities in the clinical context from the residents' perspective. Objectives: 1) To determine how frequently clinical professors perform teaching activities in the four areas: teaching, supervision, organization and interpersonal relationships, 2) to distinguish professors' performance by specialty 3) To inquire differences in the evaluation of professors according the residents' academic year. Materials and methods: The "Survey among PUEM's Students 2010" included 13 frequency questions and 2 of valuation in the section of teaching performance. Teaching activities from the four previously mentioned areas in ten specialties were considered. The sample was 1816 cases; significant associations (p <0.05) among variables were assessed. Results: In the answer choices: "always" and "almost always", interpersonal relationships obtained the highest score (>80%), the regular organization of academic and healthcare activities was mentioned in more than 2/3 of the answers. The frequency of teaching activities related to the curricular structure, and supervision were situated below average. The highest scores were for family medicine professors and the lowest for orthopedia. By academic grade, first and fifth year residents considered that teaching activities were more constant; while second year students considered them the least constant. Discussion: Personal relationships between clinical professors and residents are adequate. Students perceive themselves integrated to their wards; however the fulfillment of academic programs and supervision are not frequent enough.

[Interpersonal relationships: perception of the communication, treatment and adverse experiences encountered by users of medical units that belong to the Coordinating Commission of the National Institutes of Health and High Specialty Hospitals (CCINSHAE)]. / Las relaciones interpersonales: percepción de la comunicación, trato y experiencias adversas en los usuarios de las unidades médicas pertenecientes a la Comisión Coordinadora de Institutos Nacionales de Salud y Hospitales de Alta Especialidad (CCINSHAE).

INTRODUCTION: User's perception with regard to the attention they received in healthcare units is increasingly being taken into account by the health service providers in order to improve the quality of their service. AIM: Describe how the users perceive the health services provided by the CCINSHAE with regard to the communication with the physicians, the attention of the staff and the adverse personal and institutional experiences and to explore their relation with user's demographic characteristics, health condition, physical limitations to carry out daily activities and service area. METHODS: A questionnaire was designed to collect information about the user and his/her opinion with regard to the healthcare units, the communication with the physicians, the attention of the staff and the adverse personal and institutional experiences. The data were analyzed with STATA using sample weights. RESULTS: A total of 2,176 individuals were interviewed after they had received attention and represent a population of 1,457,964 users, over 6 months, of the CCINSAHE. We then calculated four binary variables that reflect the perception of the users. These four variables were significantly associated with the type of health unit where the user received attention, schooling, limitations to carry out daily activities, facilities provided to the relatives, family income, the use of alternative medicine, and the area of attention. DISCUSSION: A fundamental aspect of the service provided by the healthcare institutions is the communication between the physicians and the users. We found that the perception of the users with regard to the communication with the physician, the attention of the staff, and the adverse personal and institutional experiences was associated with the type of healthcare unit. The federal reference hospitals produced the most unfavorable perception while the regional hospitals produced the most favorable impression. This study enables the decision-making personnel to determine what needs to be modified in order to improve the service provided by the health units.

[Social conditions in which medical students from the faculty of medicine of the National University of Mexico (UNAM) perform their Social Service in rural areas]. / Condiciones sociales en que los pasantes de la Facultad de Medicina (FM) de la Universidad Nacional Autónoma de México (UNAM) realizan el Servicio Social en áreas rurales.

The aim of this work is to describe the conditions in which medical students perform their Social Service, highlighting their experiences in areas such as: information before they move and the motivation to leave home; the perception of personal and environmental lack of safety; the institutional support that they receive during their work in the community and the financial support provided. The methodological design of the study included an exploratory phase, in which collective interviews were performed, using the focal group technique, with students who had been in rural areas. Three hundred sixty cases were considered, 72.8% corresponded to rural areas, and 27.7% to Mexico City. According to the findings, the following actions are proposed: give better information and improve the process of vacancy selection; increase the scholarship received by students in Social Service; establish legal, police, and community support mechanisms to guarantee the student's personal safety; pay attention to aspects such as the student's emotional and social situation, and design programs with gender perspective to enhance certainty and safety.

[Impact of problem-based learning on the cognitive processes of medical students]. / Impacto del aprendizaje basado en problemas en los procesos cognitivos de los estudiantes de medicina.

The problem based learning (PBL) method was conceived as a teaching strategy to be applied in different areas or disciplines, thus several universities adopted it, among which was the Universidad Nacional Autónoma de México, best known as UNAM. The Faculty of Medicine of UNAM implemented this innovative teaching method of medicine for its learner-centered educational method tendency (patient-centered practice). This method develops also several abilities in the students, such as active and significant learning, seeking and data selection and autoanalysis and synthesis, knowledge integration of, mind's logic for the detection and solution of problems, among others. The aim was to evaluate the PBL impact on pedagogical and cognitive processes through the students' critical thinking and the significance of the experience on students and teachers which were working with PBL; in addition, study strategies and self-regulation in students were considered variables for the study. Our findings indicated that PBL was perceived differently among students and teachers, and it influenced in a positive and significant way the students' perception to solve problems and their motivation to achieve a good academic performance (p < 0.005). These results suggest that PBL is a useful strategy in the teaching and learning process and it is clear that the pedagogical process and other variables can potentially influence the results obtained.

[Recurrent pericardial effusion due to familiar Mediterranean fever]. / Pericarditis recidivante y fiebre mediterránea familiar.

Pericarditis is usually a complication of viral or bacterial infection. In addition, it can be associated to systemic diseases such as autoimmune disorders, rheumatic fever, cancer, tuberculosis and AIDS. It can also be related to familial Mediterranean fever, an autosomic recessive inflammatory disease, characterized by fever, abdominal pain, and pleuritis mainly seen in persons from the Mediterranean area. In this study, we described the evolution and treatment response to colchicine in three patients with pericarditis associated to familial Mediterranean fever. Two of the patients had a pericardiectomy showing in their biopsy nonspecified inflammatory changes. Later their diagnosis were confirmed by genetic markers, echocardiogram and EKG. They were treated with antiviral and antibiotics without any improvement; subsequently they had good results with colchicine.

[Pneumonia and its social representations]. / La neumonía y sus representaciones sociales.

OBJECTIVE: To correlate the sociostructural variables with the knowledge about pneumonia and to explore the social representations about the etiology, prevention, development and treatment in poor communities. METHODS: A survey in 848 adults from seven Rural Health Centers affiliated to IMSS-Oportunidades Program in four States, was carried out. RESULTS: One-third of the sample did not understand the term pneumonia; 35 % of the patients with risk factors did not know its etiology; 43 % did not know about associated complications but 85 % considered that it causes death. The use of antibiotics was recognized as a therapeutic measure by 78 % and 20 % did not know how to prevent pneumonia. CONCLUSION: The findings showed a positive attitude to immunization but inadequate information about respiratory diseases. In neighborhoods with insufficient public services (purified water, electricity and paved roads) the ignorance about pneumonia tended to increase.

[Social capital, poverty and self-perception of family support in cases of acute respiratory illness]. / Capital social, pobreza familiar y autopercepción de apoyo en casos de enfermedad respiratoria aguda.

The aim of this study was to correlate the socio structural variables of the Simplified Index of Family Poverty with the self-perception of resources that conform social capital among patients with acute respiratory disease (ARD). We used a qualitative and quantitative methodology. The sample included 848 cases distributed in seven Rural Medicine Units of Mexico. We considered three pathways described by Kawachi where social capital might have an impact on individual health. The bivariate correlation and discriminant analysis showed that when there is evidence of poverty in the family, the statistically significant differences are mainly observed in self-perception. Moral support of sons and daughters is thereby increased when there is an ARD. We concluded that when there is a higher index of family poverty there is a decreased access to social resources when a family member is diagnosed with an ARD.