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.

Mapping an EPA-based comprehensive curricular proposal for UME.

This article was migrated. The article was marked as recommended. In medical education, there have been three important reforms: science-based curriculum, problem-based learning, and competency-based education. Currently, the concept of Entrustable Professional Activities (EPA) goes a step beyond competencies. The aim of this paper is twofold: first, to present a proposal for an EPA-based curriculum for undergraduate medical education, and second, to describe its curricular framework, educational model and organization. This curricular proposal integrates EPA-based education with the foundations of the interpretive epistemology, the constructivist paradigm and the health care transformations. Using Actividades Profesionales Confiables (APROC) as a curricular guideline helps the educators define knowledge, skills, and attitudes; teachers can plan activities that link theory to practice; evaluators can assess the student's performance and provide him with feedback, and Faculty leaders and collaborators can implement projects to improve educational quality. The curriculum proposal includes a flexible modular system, the integration of biomedical, socio-medical and clinical sciences, and a close link between theory and practice. This curriculum puts medical education at the forefront, it favors the comprehensive education of future physicians, and it constitutes a true educational revolution.

Burnout en estudiantes del Plan de Estudios Combinados en Medicina, Facultad de Medicina, Universidad Nacional Autónoma de México / Burnout in students of the Program of Combined Studies in Medicine, Faculty of Medicine, National Autonomous University of Mexico

Introducción: El Plan de Estudios Combinados en Medicina está diseñado para que alumnos sobresalientes que cursan la carrera de medicina estudien el doctorado simultáneamente. Las exigencias para culminar el posgrado involucran situaciones de estrés que podrían llevar al desgaste. El burnout es un síndrome con tres dimensiones: agotamiento emocional, cinismo e ineficacia, que pueden disminuir las expectativas de éxito, satisfacción y rendimiento académico. Objetivo: Determinar la frecuencia de burnout y sus dimensiones en estudiantes de seis generaciones del programa, así como su correlación con características sociodemográficas, académicas y hábitos. Sujetos y métodos: Los alumnos respondieron voluntariamente un cuestionario autoaplicado y el Maslach Burnout Inventory-Student Survey. Se calculó la prevalencia de las dimensiones del burnout y se correlacionaron con variables evaluadas en el cuestionario usando la prueba exacta de Fisher. Resultados: Los 56 participantes no presentaron burnout y un 61% tampoco las dimensiones del síndrome. Solas o combinadas, un 27% mostró ineficacia; un 11%, cinismo, y un 7%, agotamiento. La prevalencia de dos dimensiones fue del 5%. Se encontraron diferencias significativas (p < 0,05) para la relación con el grupo, tocar un instrumento, cantar o actuar, sitio de residencia y la violencia en el traslado. Conclusiones: La ausencia de burnout en los participantes posiblemente refleja satisfacción y compromiso académico. La pésima relación con compañeros y la violencia en el traslado son frecuentes en alumnos con agotamiento. Es posible que tocar un instrumento, cantar o actuar constituya una respuesta al agotamiento y al cinismo, así como otras estrategias de afrontamiento no exploradas en este estudio

Introduction: Combined Studies in Medicine is a program in which outstanding students pursue a career in Medicine and simultaneously a doctorate. The requirements to complete the graduate course involve stress situations that could lead to burnout. Burnout is a syndrome with three dimensions: emotional exhaustion, cynicism and inefficiency, which can diminish the expectations of success, satisfaction and academic performance. Aim: To determine the frequency of burnout and its dimensions in students of six generations of the program as well as its correlation with habits, sociodemographic and academic characteristics. Subjects and methods: Students voluntarily answered a self-applied questionnaire and the Maslach Burnout InventoryStudent Survey. The prevalence of the dimensions and burnout were calculated and were correlated with variables evaluated in the questionnaire using the Fisher's exact test. Results: The 56 participants were negative to burnout and 61% to the dimensions; 27% had inefficiency, 11% cynicism and 7% exhaustion, combined or alone. The prevalence of two dimensions was 5%. Significant differences were found (p < 0.05) for the relationship with colleagues, playing instruments, singing/acting, place of residence and violence on the way to the stay. Conclusions: The absence of burnout in the participants possibly reflects satisfaction and academic commitment. The bad relationship with colleagues and the violence on their way to the stay are frequent in students with exhaustion. It is possible that playing instruments, singing or acting was a response to exhaustion and cynicism, as well as other coping strategies not explored in this study

Avances del Modelo Educativo para Desarrollar Actividades Profesionales Confiables (MEDAPROC) / Advances of an Educational Model to Develop Entrustable Professional Activities (MEDAPROC)

El Modelo Educativo para Desarrollar Actividades Profesionales Confiables (MEDAPROC) surge como respuesta a la implementación de la educación basada en competencias. Es un proyecto multidisciplinario fundamentado en la epistemología interpretativa, el paradigma constructivista, las transformaciones del Sistema Nacional de Salud y el contexto del ejercicio actual de la medicina. Su meta es favorecer la adquisición de conocimientos, habilidades y actitudes indispensables por parte del estudiante de medicina. Integra la tendencia internacional de las Entrustable Professional Activities y las naturaliza como las Actividades Profesionales Confiables (APROC). MEDAPROC propone que el desarrollo de las APROC se promueva de manera inversa, desde el perfil de egreso hasta el inicio de los estudios de pregrado, por lo tanto, se involucra en diversas fases y procesos de aprendizaje y enseñanza (planeación, didáctica, evaluación y realimentación) por medio de proyectos para implementar estrategias didácticas y recursos de evaluación, con el apoyo de la formación docente, la investigación educativa y la tecnología. Su objetivo es lograr la mejora de la educación médica y de las ciencias de la salud, con el firme propósito de generar un cambio positivo en la calidad de la atención desde el entorno educativo

The Educational Model to Develop Entrustable Professional Activities (MEDAPROC) arises as a response to the implementation of competency-based education. It is a multidisciplinary project based on interpretative epistemology, the constructivist paradigm, the transformations of the national health system, and the context of the current practice of medicine. Its purpose is to encourage the acquisition of essential knowledge, skills, and attitudes by the medical student. It integrates the international trend of the entrustable professional activities and converts them into entrustable professional activities (APROC). MEDAPROC proposes that the development of the APROC be promoted in an inverse manner, from the profile of the graduate to the beginning of the undergraduate studies. Therefore, it is involved in several phases of the learning and teaching process (planning, didactics, assessment, and feedback) through projects to implement didactic strategies and assessment resources, with the support of teacher training, educational research, and technology. Its aim is to improve medical and health sciences education, with the firm purpose of making a positive change in the health care quality from the educational environment

¿Qué opinan los residentes sobre sus profesores? Un enfoque cualitativo / What do residents think about their tutors? A qualitative approach

INTRODUCCIÓN: La interacción de los profesores con los estudiantes, la supervisión de las prácticas clínicas y el profesionalismo son temas que explora el instrumento de evaluación del desempeño docente que recoge la opinión de los residentes sobre las competencias educativas de profesores titulares y adjuntos. OBJETIVO: 1)Recuperar los testimonios de los residentes sobre el modelo de rol y el compromiso de sus profesores con su aprendizaje; 2)reconocer las estrategias educativas empleadas por los docentes en contextos clínicos; 3)visibilizar las dificultades de contratación en la planta académica actual del PUEM que afectan el proceso educativo, y 4)reportar las menciones de maltrato y percepción de injusticia de los residentes por sus profesores. MATERIAL Y MÉTODO: Estudio cualitativo que consideró los comentarios a pregunta abierta de 1.628 residentes sobre el desempeño docente en las residencias médicas. Se clasificaron en 10 categorías con subcategorías y se cuantificaron las tendencias positiva y negativa. Posteriormente se analizaron los testimonios de acuerdo a los 3 temas del cuestionario. RESULTADOS: Para los residentes, las categorías del profesor como modelo a seguir y el compromiso académico del docente obtuvieron el mayor número de opiniones positivas, mientras que la contratación del profesor y las estrategias educativas empleadas por este último reportaron el mayor número de comentarios negativos. DISCUSIÓN: Los comentarios libres que plasmaron los residentes sobre el desempeño docente reflejan las fortalezas y debilidades del proceso educativo en contextos hospitalarios, lo que permite un acercamiento cualitativo a la relación con sus profesores

INTRODUCTION: Teacher and student interaction, the monitoring of clinical practices, and professionalism are the issues that the teaching performance assessment tool examines by gathering the opinions of the residents on the educational skills of teaching staff and lecturers. OBJECTIVE: The aim of this study was to: (I)gathering the comments of the residents about the role model and commitment of tutors to their training; (II)to determine the educational strategies used by teachers in clinical settings; (III)to show the current recruitment difficulties of the Medical Specialisations Plan (PUEM) affect the educational process, and (IV)to report the residents mentions of abuse and perceived unfairness by their teachers. MATERIAL AND METHOD: Qualitative study that considered the written comments by 1,628 residents in an open question regarding teaching performance in medical residencies. They were classified into 10 categories with sub-categories and the positive and negative trends were quantified. The comments were analysed according to the 3 topics of the questionnaire. RESULTS: For residents, the categories of the educator as role model and academic commitment of the teacher obtained the largest number of positive reviews, while hiring of teachers and educational strategies employed by the latter reported the highest number of negative comments. DISCUSSION: The free comments expressed by the residents on the teaching performance reflect the strengths and weaknesses of the teaching process in hospital contexts, which provides a qualitative approach to the relationship with their teachers

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.

La evaluación de los docentes desde la perspectiva de los médicos residentes del Plan Único de Especializaciones Médicas / Faculty performance assessment by residents in medical specialties

INTRODUCCIÓN: El rol del profesor ha cambiado, al ser un guía que facilita el aprendizaje. Mediante la opinión de los médicos residentes se buscó conocer el desempeño docente y el proceso educativo en contextos clínicos. OBJETIVO: El objetivo fue calificar al docente en 3 ámbitos: interacción en las actividades académico-asistenciales, supervisión de la práctica médica y profesionalismo. MATERIAL Y MÉTODO: Se elaboró un cuestionario de evaluación docente con 29 reactivos con opciones de respuesta tipo Likert, validado y aplicado en línea a 8.742 residentes inscritos de 78 especialidades del ciclo 2014-2015. Respondieron 2.604 residentes de 101 sedes que evaluaron a 1.173 docentes. El número de evaluaciones registradas fue de 9.591. Se utilizó estadística descriptiva para analizar los datos y asignar las calificaciones. RESULTADOS: Cerca del 85% de los residentes se agruparon en las áreas quirúrgicas y clínicas. El 78% reportaron estar satisfechos o muy satisfechos con su proceso educativo. El área quirúrgica fue la mejor evaluada, seguida de las especialidades clínicas. Los residentes de niveles avanzados concedieron mayores puntuaciones. DISCUSIÓN: Existió coincidencia en la alta puntuación del área quirúrgica con otros estudios realizados en hospitales. CONCLUSIONES: Este estudio multicéntrico aportó datos útiles, como el promedio por área y especialidad. La opinión de los estudiantes es solo un elemento entre varios a considerar al evaluar el desempeño docente, pero contribuye a la rendición de cuentas y a la elevación de la calidad de la formación profesional

INTRODUCTION: The role of the teacher has changed to being a guide that facilitates learning. Using the opinions of medical residents an attempt was made to determine the teacher performance and the educational process in clinical settings. OBJECTIVE: The objective was to assign a grade to the teachers in three areas: interaction in academic and welfare activities, supervision of medical practice and professionalism. MATERIAL AND METHOD: A 29 items questionnaire with Likert response options was developed, validated and applied online to 8,742 registered residents of 78 specialties in the 2014-2015 courses. A response was received from a total of 2,604 residents from 101 medical units (clinics and hospitals), who evaluated 1,173 teachers. The number of registered assessments was 9,591. Descriptive statistics was used to analyse the data and assign grades. RESULTS: About 85% of residents were grouped in surgical and clinical areas, with 78% reporting being satisfied or very satisfied with their education. The surgical area was the best evaluated, followed by clinical specialties. Residents of more advanced levels gave high scores. DISCUSSION: There was agreement with studies conducted in other hospitals on the high score of the surgical area. CONCLUSIONS: This multicentre study provided useful data, such as the mean score by areas and specialties. The opinion of students is only one aspect among several to consider when evaluating teacher performance, but contributes to accountability and raising the quality of vocational training

[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.

Actividades profesionales confiables (APROC): un enfoque de competencias para el perfil médico / Entrustable Professional Activities (EPA): an approach of competencies for medical curriculum

La implementación de la educación basada en competencias ha revolucionado de manera global la forma de aprender y enseñar medicina. Las competencias corresponden a las atribuciones que todo médico debe de poseer, y surgieron a partir de las Canadian Medical Education Directives for Specialists y el Accreditation Council for Graduate Medical Education (ACGME). Para lograr su adquisición, ha sido necesario implementar las actividades profesionales confiables (APROC), término acuñado por Ten Cate y Scheele, cuya finalidad ha sido vincular el concepto de competencias con la práctica. Se trata de actividades clínicas que los aprendices deben realizar para lograr dominarlas sin supervisión. El Milestone Project creado por el ACGME surgió para enriquecer las competencias, y cada especialidad debe definir las propias y decidir el nivel de desempeño que espera de sus alumnos en cada año de la especialidad. Para lograr aplicar las APROC es necesario que su diseño sea acorde con los objetivos del plan de estudios y requisitos del perfil del graduado. Diversas instituciones educativas de diferentes países han implementado este innovador modelo de enseñanza, entre los que destacan Canadá, Estados Unidos, Reino Unido, Australia, Nueva Zelanda y Países Bajos. El propósito de este artículo es difundir nuevas propuestas para la educación médica que logren vincular el perfil de competencias con la práctica clínica rutinaria, para que los facultativos logren empoderamiento de estas nuevas herramientas y las puedan aplicar de manera eficiente en la enseñanza de los estudiantes, y una de éstas son las APROC

The implementation of competency-based education has revolutionized the way of learning and teaching medicine globally. Competencies are the responsibilities that all physicians must possess; they emerged from the Canadian Medical Education Directives for Specialists (CanMEDS) and Accreditation Council for Graduate Medical Education (ACGME). To achieve the acquisition of these competencies, it has been necessary to implement Entrustable Professional Activities (EPAs), term coined by Ten Cate and Scheele, its purpose has been to link the concept of competencies with the practice. EPAs are clinical activities that learners must carry out for master them without supervision. The Milestone Project created by the ACGME was founded in order to enrich the competencies, where each specialty should define their own and decide the level of performance expected of students in each postgraduate year of the specialty. To apply the EPAs it is necessary that its design is consistent with the objectives of the curriculum and requirements of the profile of the graduate. Several educational institutions in different countries have implemented this innovative model of teaching, including: Canada, United States of America, United Kingdom, Australia, New Zealand and the Netherlands. The purpose of this article is to spread new proposals for medical education that link the competencies with the daily basis practice in medicine to allow clinicians to achieve empowerment of these new tools and can apply them efficiently to the teaching of students, being one of these tools the EPAs

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.